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Muldoon RL, Bethurum AJ, Gamboa AC, Zhang K, Ye F, Regenbogen SE, Abdel-Misih S, Ejaz A, Wise PE, Silviera M, Holder-Murray J, Balch GC, Hawkins AT. Comparison of outcomes of abdominoperineal resection vs low anterior resection in very-low rectal cancer. J Gastrointest Surg 2024; 28:1450-1455. [PMID: 38897287 DOI: 10.1016/j.gassur.2024.06.008] [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] [Received: 09/11/2023] [Revised: 05/31/2024] [Accepted: 06/09/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal resection (APR) over low anterior resection (LAR) to optimize oncologic outcomes. This study aimed to determine differences in long-term oncologic outcomes between patients undergoing APR or LAR for very-low rectal cancer. METHODS The United States Rectal Cancer Consortium (2010-2016) was queried for adults who underwent either APR or LAR for stage I-III rectal cancers < 5 cm from anorectal junction and met inclusion criteria. The primary outcome was disease-free survival. Secondary outcomes included overall survival, length of stay, complications, recurrence location, and perioperative factors. RESULTS A total of 431 patients with very-low rectal cancer who underwent APR or LAR were identified; 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. The median follow-up was 42.5 months. An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types (APR-hazard ratio [HR] = 0.90, 95% CI: 0.53-1.52, P = .70). Secondary outcomes demonstrated no significant difference between operation types, including overall survival (HR = 1.29, 95% CI: 0.71-2.32, P = .39), complications (OR = 1.53, 95% CI: 0.94-2.50, P = .12), or length of stay (estimate: 0.04, SE = 0.25, P = .54). CONCLUSION We observed no significant difference in disease-free survival or overall survival between patients undergoing APR or LAR for very-low rectal cancer. This analysis supports the treatment of very-low rectal cancer, without sphincter involvement, by either APR or LAR.
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Affiliation(s)
- Roberta L Muldoon
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University, Nashville, TN, United States
| | - Alva J Bethurum
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University, Nashville, TN, United States
| | - Adriana C Gamboa
- Department of Surgery, Emory University, Atlanta, GA, United States
| | - Kevin Zhang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Sherif Abdel-Misih
- Division of Surgical Oncology, Department of Surgery, Stony Brook University, Stony Brook, NY, United States
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, United States
| | - Paul E Wise
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew Silviera
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Glen C Balch
- Division of Colorectal Surgery, Department of Surgery, Emory University, Atlanta, GA, United States
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University, Nashville, TN, United States.
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Faier TAS, Queiroz FL, Lacerda-Filho A, Paiva RA, França Neto PR, Cortes MGW, Carvalho ARDE, Pereira BMT. Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision. Rev Col Bras Cir 2023; 50:e20233435. [PMID: 37531500 PMCID: PMC10508657 DOI: 10.1590/0100-6991e-20233435-en] [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: 08/03/2022] [Accepted: 03/28/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). METHODS we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. RESULTS sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). CONCLUSION rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.
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Kim JC, Lee JL, Kim CW, Kim JR, Kim J, Park SH. Technical, functional, and oncological validity of robot-assisted total-intersphincteric resection (T-ISR) for lower rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:188-195. [PMID: 35864011 DOI: 10.1016/j.ejso.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/14/2022] [Accepted: 07/08/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Few studies fairly compared anorectal function and prognostic outcomes between patients undergoing abdominoperineal resection (APR) and anorectal-function-saving operations (ASO) under the equivalent conditions. By contrast, surgeons used to be somewhat hesitant to conduct total intersphincteric resection (T-ISR) as maximal ASO, due to its technical complexity and potential anorectal dysfunction. METHODS Propensity-score matched cohorts undergoing robot-assisted R0 surgery [T-ISR vs APR vs partial-subtotal ISR (PS-ISR)/lower anterior resection (LAR)] for rectal cancer (n = 1361) were included. Operative outcomes, recurrence, and disease-free/overall survival (DFS/OS) were analyzed. Anorectal function was evaluated based on fecal incontinence score and high-resolution manometry between the T-ISR and other ASO groups. RESULTS Few differences were detected between the T-ISR and APR groups. More patients undergoing APR had T4 stage disease, while the lowest tumor margin was the same in both groups (mean, 1.5 cm from anal verge). Prognostic outcomes did not differ between the T-ISR and APR groups, including local (5.1% vs 7.7%, p = 1) or systemic (15.4% vs 25.6%, p = 0.401) recurrence, and 5-year DFS (78.7% vs 61.5%, p = 0.1) and OS (89% vs 82.1%, p = 0.434) rates, nor were there differences between the T-ISR and PS-ISR/LAR groups. The PS-ISR group generally showed less anorectal dysfunction than the T-ISR group, but maximal tolerance volume did not differ between these two groups and was within the range for the healthy population. CONCLUSIONS T-ISR can replace most traditional APR, except for advanced T4 disease with aggressive infiltration into the levator-sphincters, and can provide tolerable anorectal dysfunction.
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Affiliation(s)
- Jin Cheon Kim
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
| | - Jong Lyul Lee
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jung Rang Kim
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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Saadoun JE, Meillat H, Zemmour C, Brunelle S, Lapeyre A, de Chaisemartin C, Lelong B. Nomogram to predict disease recurrence in patients with locally advanced rectal cancer undergoing rectal surgery after neoadjuvant therapy: retrospective cohort study. BJS Open 2022; 6:6901342. [PMID: 36515671 DOI: 10.1093/bjsopen/zrac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/17/2022] [Accepted: 10/01/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Prognostic models can be used for predicting survival outcomes and guiding patient management. TNM staging alone is insufficient for predicting recurrence after chemoradiotherapy (CRT) and surgery for locally advanced rectal cancer. This study aimed to develop a nomogram to better predict cancer recurrence after CRT followed by total mesorectal excision (TME) and tailor postoperative management and follow-up. MATERIALS AND METHODS Between 2002 and 2019, data were retrospectively collected on patients with rectal adenocarcinoma. Data on sex, age, carcinoembryonic antigen (CEA) level, tumour location, induction chemotherapy, adjuvant chemotherapy, tumour downsizing, perineural invasion, lymphovascular invasion, pathological stage, resection margins (R0 versus R1), and pelvic septic complications were analysed. The variables significantly associated with cancer recurrence were used to build a nomogram that was validated in both the training and validation cohorts. Model performance was evaluated by receiver operating characteristic curve and area under the curve (AUC) analyses. RESULTS After applying exclusion criteria, 634 patients with rectal adenocarcinoma were included in this study. Eight factors (CEA level, adjuvant chemotherapy, tumour downsizing, perineural invasion, lymphovascular invasion, pathological stage, resection margins (R0 versus R1), and pelvic septic complications) were identified as nomogram variables. Our nomogram showed good performance with an AUC of 0.74 and 0.75 in the training and validation cohorts respectively. CONCLUSION Our nomogram is a simple tool for predicting cancer recurrence in patients with locally advanced rectal cancer after neoadjuvant CRT followed by TME. It provides an individual risk prediction of recurrence to tailor surveillance.
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Affiliation(s)
| | - Hélène Meillat
- Department of Digestive and Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Investigation, Biostatistics and Methodology Unit, Paoli-Calmettes Institute, Marseille, France
| | - Serge Brunelle
- Department of Radiology, Institut Paoli-Calmettes, Marseille, France
| | - Alexandra Lapeyre
- Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Cécile de Chaisemartin
- Department of Digestive and Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Bernard Lelong
- Department of Digestive and Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
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Lee HG, Kim CW, Lee JL, Yoon YS, Park IJ, Lim SB, Yu CS, Kim JC. Comparative survival risks in patients undergoing abdominoperineal resection and sphincter-saving operation for rectal cancer: a 10-year cohort analysis using propensity score matching. Int J Colorectal Dis 2022; 37:989-997. [PMID: 35378615 DOI: 10.1007/s00384-022-04138-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in patients with rectal cancer. This study compared long-term oncologic outcomes and prognostic parameters in propensity score-matched patients who underwent APR and SSO. METHODS This study analyzed 958 consecutive patients with lower rectal cancer who underwent preoperative chemoradiotherapy followed by APR or SSO between 2005 and 2015. Propensity score matching analysis was performed to adjust baseline characteristics, including clinical stage, tumor distance from the anal verge, and tumor size. RESULTS In the entire cohort, the APR group had larger and lower tumors and showed significantly shorter 5-year disease-free survival (DFS) than the SSO group (64.5% vs. 75.8%, p = 0.01). After propensity score matching, there were no significant between-group differences in local (9.5% vs. 8.0%, p = 0.59) and systemic (27.9% vs. 23.4%, p = 0.3) recurrence rates, and 5-year DFS (67.5% vs. 69.9%, p = 0.49) and overall survival (80.8% vs. 82.9%, p = 0.65) rates. A lower number of lymph nodes retrieved was independently associated with recurrence and survival outcomes in the APR group, whereas poorly differentiated histology was an independent associated parameter in the SSO group. Advanced stage and perineural invasion were identified as independent prognostic parameters in both groups. CONCLUSIONS This study indicated that the long-term oncologic outcomes of APR were comparable to those of SSO. Because prognostic parameters associated with oncologic outcomes differed between the respective procedures, correctable parameters could be ameliorated through complete total mesorectal excision and personalized systemic treatment.
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Affiliation(s)
- Hyun Gu Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Moraru DC, Scripcariu DV, Ferariu D, Scripcariu V, Filip B. Perineal eventration after abdominoperineal resection for rectal cancer: anatomical, surgical and clinico-pathological landmarks. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY 2021; 61:1111-1119. [PMID: 34171060 PMCID: PMC8343492 DOI: 10.47162/rjme.61.4.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of evolution, out of 620 patients with rectal cancer treated by curative surgery, 176 patients with lower ampullary rectal cancer treated by abdominoperineal resection (APR) with the closure of the defect by direct suture of the perineal floor were selected. Ten (5.6%) of them were diagnosed with PE. This paper shows the results of a retrospective study, which compares the clinico-pathological and therapeutic aspects of a subgroup of 166 patients (subgroup I) with APR without PE and a subgroup of 10 patients (subgroup II) with PE. Starting from the question of whether aspects can influence the evolution of PE, we aimed to investigate the similarities and differences between these two groups, from the histological, clinical and therapeutic points of view. Regarding the tumor, node, metastasis (TNM) staging, we encountered the following aspects: for the subgroup II with PE, pT3 predominated, stages N0 and N1 were equal (50%) and the absence of metastases (M0) was found in all cases; in subgroup I, pT3 and N0 also predominated, followed by N1 and N2, and for stage M, M0 is predominant, followed by M1. For the clinical profile of the PE group, the symptoms were characteristic, with the presence of the usual triggering factors [hysterectomy, radiochemotherapy and wide resection surgery – extralevatorial APR]. The therapeutic approach revealed various aspects, including plastic surgery procedures (direct closure, meshes, flaps) used in pelvic reconstruction. The accurate surgical technique applied in order to achieve oncological safety allowed for a longer survival, which favored the appearance of PE in addition to the other favoring factors. Our results underlined the clinico-pathological profile of the two subgroups, without being able to establish a correlation with the appearance and evolution of PE. However, the clinico-pathological risk factors for this condition are not yet fully defined. Therefore, reports based on the experience in the diagnosis and treatment of PE should bring valuable data, aiming to create the knowledge framework for prevention.
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Affiliation(s)
- Dan Cristian Moraru
- Department of Surgery I, Grigore T. Popa University of Medicine and Pharmacy, 1st Surgical Oncology Unit, Regional Institute of Oncology, Iaşi, Romania;
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Improved Outcomes for Rectal Cancer in the Era of Preoperative Chemoradiation and Tailored Mesorectal Excision: A Series of 338 Consecutive Cases. Am Surg 2020. [DOI: 10.1177/000313481307900225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N1 disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.
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Nahas S, Nahas C, Bustamante-Lopez L, Pinto R, Marques C, Cecconello I. Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Nahas SC, Nahas CSR, Bustamante-Lopez LA, Pinto RA, Marques CFS, Cecconello I. Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:180-189. [PMID: 32057523 DOI: 10.1016/j.rgmx.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/19/2019] [Accepted: 05/30/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND AIM Surgery for distal rectal cancer (DRC) can be performed with or without sphincter preservation. The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients: low anterior resection (LAR) and abdominoperineal resection (APR). METHODS Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated. We compared the outcomes of the type of surgery (APR vs LAR) and analyzed the associations of survival and recurrence with the following factors: age, sex, tumor location, lymph nodes obtained, lymph node involvement, and rectal wall involvement. Patients with distant metastases were excluded. RESULTS A total of 148 patients were included, 78 of whom were females (52.7%). The mean patient age was 61.2years. Neoadjuvant chemoradiation therapy was performed in 86.5% of the patients. APR was performed on 86 (58.1%) patients, and LAR on 62 (41.9%) patients. No differences were observed between the two groups regarding clinical and oncologic characteristics. Eighty-seven (62%) patients had pT3-4 disease, and 41 patients (27.7%) had lymph node involvement. In the multivariate analysis, only poorly differentiated tumors (P=.026) and APR (P=.009) correlated with higher recurrence rates. Mean follow-up time was 32 (16-59.9) months. Overall 5-year survival was 58.1%. The 5-year survival rate was worse in patients that underwent APR (46.5%) than in the patients that underwent LAR (74.2%) (P=.009). CONCLUSIONS Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR. In addition, advanced T/stage, lymph node involvement, and poor tumor differentiation were associated with recurrence and a lower survival rate, regardless of the procedure.
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Affiliation(s)
- S C Nahas
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - C S R Nahas
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - L A Bustamante-Lopez
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil.
| | - R A Pinto
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - C F S Marques
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - I Cecconello
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
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Rencuzogullari A, Abbas MA, Steele S, Stocchi L, Hull T, Binboga S, Gorgun E. Predictors of one-year outcomes following the abdominoperineal resection. Am J Surg 2019; 218:119-124. [DOI: 10.1016/j.amjsurg.2018.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/12/2018] [Accepted: 08/26/2018] [Indexed: 11/16/2022]
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Oncologic outcomes for low rectal adenocarcinoma following low anterior resection with coloanal anastomosis versus abdominoperineal resection: a National Cancer Database propensity matched analysis. Int J Colorectal Dis 2019; 34:843-848. [PMID: 30790033 DOI: 10.1007/s00384-019-03267-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Low anterior resection with coloanal anastomosis (CAA) for low rectal cancer is a technically difficult operation with limited data available on oncologic outcomes. We aim to investigate overall survival and operative oncologic outcomes in patients who underwent CAA compared to abdominoperineal resection (APR). METHODS The National Cancer Database (2004-2013) was used to identify patients with non-metastatic rectal adenocarcinoma who underwent CAA or APR. Patients were 1:1 matched on age, gender, Charlson score, tumor size, tumor grade, pathologic stage, and radiation treatment with propensity scores. The primary outcome was overall survival. Secondary outcomes included 30-day mortality and resection margins. RESULTS Following matching, 3536 patients remained in each group. No significant differences in matched demographic, treatment, or tumor variables were seen between groups. There was no significant difference in 30-day mortality (1.24% vs. 1.39%, p = 0.60). Following resection, margins were more likely to be negative after CAA compared with APR (5.26% vs. 8.14%, p < 0.001). When stratified by pathologic stage, there was a significant survival advantage for individuals undergoing CAA compared to APR (stage 1 HR 0.72, [95% CI 0.62-0.85], p < 0.001; stage 2 HR 0.76, [95% CI 0.65-0.88], p < 0.001; stage 3 HR 0.76, [95% CI 0.67-0.85], p < 0.001). CONCLUSIONS Patients undergoing CAA compared with APR for rectal cancer have better overall survival and are less likely to have positive margins despite the technically challenging operation.
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Outcomes of Rectal Cancer Patients With Low Sphincter-Preserving Operations Compared to Patients With Abdominoperineal Resection. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0404-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Warschkow R, Ebinger SM, Brunner W, Schmied BM, Marti L. Survival after Abdominoperineal and Sphincter-Preserving Resection in Nonmetastatic Rectal Cancer: A Population-Based Time-Trend and Propensity Score-Matched SEER Analysis. Gastroenterol Res Pract 2017; 2017:6058907. [PMID: 28197206 PMCID: PMC5286526 DOI: 10.1155/2017/6058907] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/15/2016] [Indexed: 12/13/2022] Open
Abstract
Background. Abdominoperineal resection (APR) has been associated with impaired survival in nonmetastatic rectal cancer patients. It is unclear whether this adverse outcome is due to the surgical procedure itself or is a consequence of tumor-related characteristics. Study Design. Patients were identified from the Surveillance, Epidemiology, and End Results database. The impact of APR compared to coloanal anastomosis (CAA) on survival was assessed by Cox regression and propensity-score matching. Results. In 36,488 patients with rectal cancer resection, the APR rate declined from 31.8% in 1998 to 19.2% in 2011, with a significant trend change in 2004 at 21.6% (P < 0.001). To minimize a potential time-trend bias, survival analysis was limited to patients diagnosed after 2004. APR was associated with an increased risk of cancer-specific mortality after unadjusted analysis (HR = 1.61, 95% CI: 1.28-2.03, P < 0.01) and multivariable adjustment (HR = 1.39, 95% CI: 1.10-1.76, P < 0.01). After optimal adjustment of highly biased patient characteristics by propensity-score matching, APR was not identified as a risk factor for cancer-specific mortality (HR = 0.85, 95% CI: 0.56-1.29, P = 0.456). Conclusions. The current propensity score-adjusted analysis provides evidence that worse oncological outcomes in patients undergoing APR compared to CAA are caused by different patient characteristics and not by the surgical procedure itself.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
- Institute of Medical Biometry and Informatics, University of Heidelberg, 69120 Heidelberg, Germany
| | - Sabrina M. Ebinger
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
- Department of Surgery, Hospital of Thun, 3600 Thun, Switzerland
| | - Walter Brunner
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
| | - Bruno M. Schmied
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
| | - Lukas Marti
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
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Herrinton LJ, Altschuler A, McMullen CK, Bulkley JE, Hornbrook MC, Sun V, Wendel CS, Grant M, Baldwin CM, Demark-Wahnefried W, Temple LKF, Krouse RS. Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery. CA Cancer J Clin 2016; 66:387-97. [PMID: 26999757 PMCID: PMC5618707 DOI: 10.3322/caac.21345] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/13/2016] [Accepted: 02/09/2016] [Indexed: 12/14/2022] Open
Abstract
For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.
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Affiliation(s)
- Lisa J Herrinton
- Senior Research Scientist, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Andrea Altschuler
- Senior Consultant, Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Carmit K McMullen
- Investigator, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Joanna E Bulkley
- Senior Research Associate, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Mark C Hornbrook
- Chief Scientist, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Virginia Sun
- Assistant Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA
| | - Christopher S Wendel
- Research Instructor, Arizona Center on Aging, University of Arizona College of Medicine, Tucson, AZ
| | - Marcia Grant
- Distinguished Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA
| | - Carol M Baldwin
- Professor Emerita and Southwest Borderlands Scholar, College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ
| | - Wendy Demark-Wahnefried
- Professor and Webb Endowed Chair of Nutrition Sciences, Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL
| | - Larissa K F Temple
- Colorectal Surgical Oncologist, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert S Krouse
- Staff General and Oncologic Surgeon, Professor of Surgery, Southern Arizona Veterans Affairs Health Care System and University of Arizona College of Medicine, Tucson, AZ
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De Nardi P, Summo V, Vignali A, Capretti G. Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis. Ann Surg Oncol 2015; 22:2997-3006. [PMID: 25605518 DOI: 10.1245/s10434-015-4368-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Indexed: 12/27/2024]
Abstract
BACKGROUND The extended, extralevator abdominoperineal excision has been described with the aim of improving oncological low rectal cancer patient outcomes. MATERIALS AND METHODS A systematic literature review was conducted using Medline/PubMed, Embase, Cochrane library, and Ovid for standard and extralevator abdominoperineal rectal cancer excision studies between 1995 and 2013. A total of 1,270 articles were identified and screened, and of these, 58 reports (1 randomized, 5 case-control and 52 cohort studies) were included for the qualitative analysis, and 6 were included for the quantitative analysis. The primary endpoints included intraoperative tumor perforation, the circumferential resection margin involvement, local recurrence rate, and the perineal wound complication rate. The secondary endpoints included the length of postoperative hospital stay and quality of life. Comprehensive Rev Men, version 5.2 was used for the statistical calculations. RESULTS A significant difference in the circumferential resection margin involvement rate [odds ratio (OR) 2.9; p < .001], intraoperative perforation (OR 4.30; p < .001), local recurrence rate (OR 2.52; p = .02), and length of hospital stay (OR 1.06; p < .001) in favor of the extended group was observed. Additionally, the perineal wound complications were higher in the extended group (OR 0.62; p = .007). No difference in quality of life was observed. CONCLUSIONS Our analysis confirms the oncological advantages of the extended abdominoperineal excision method. Although the perineal wound complications were higher, the length of postoperative hospital stay was shorter, and quality of life was not inferior to the conventional resection method.
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Affiliation(s)
- Paola De Nardi
- Department of Surgery, San Raffaele Scientific Institute, Milan, Italy,
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Sun Z, Yu X, Wang H, Ma M, Zhao Z, Wang Q. Factors affecting sphincter-preserving resection treatment for patients with low rectal cancer. Exp Ther Med 2015; 10:484-490. [PMID: 26622341 DOI: 10.3892/etm.2015.2552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 03/17/2015] [Indexed: 01/07/2023] Open
Abstract
The aim of the present study was to identify the factors associated with the use of sphincter-preserving resection (SPR) surgery for the treatment of low rectal cancer. A total of 330 patients with histopathologically confirmed low rectal cancer were divided into two groups, namely the abdominoperineal resection (APR) and sphincter-preserving (SP) groups. For SPR factor analysis, the χ2 test was performed as the univariate analysis, while a logistic regression test was conducted as the multivariate analysis. Of the 330 patients, 192 cases (58.18%) received SPR surgery and 138 cases (41.82%) underwent an APR. Univariate analysis results revealed that the sphincter-preserving factor was significantly associated with age, gender, ethnicity, body mass index (BMI), total infiltrated circumference, distance of the tumor from the anal verge (DTAV), depth of invasion and tumor grade (P<0.05). However, there were no statistically significant associations with family medical history, diabetes history, venous tumor embolism, growth type, tumor length, lymphatic metastasis and level of preoperative carcinoembryonic antigen (P>0.05). Multivariate analysis indicated that the sphincter-preserving factor was strongly associated with DTAV and the depth of invasion, with significant statistical difference (P<0.05). Therefore, selecting SPR surgery for patients with low rectal cancer is dependent on age, gender, ethnicity, BMI, the total infiltrated circumference, DTAV, depth of invasion and tumor grade. In addition, DTAV and the depth of invasion are independent risk factors for the selection of SPR surgery.
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Affiliation(s)
- Zhenqiang Sun
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China ; Research Laboratory of Disease Genomics, Cancer Research Institute, Central South University, Changsha, Hunan 410078, P.R. China
| | - Xianbo Yu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
| | - Haijiang Wang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
| | - Ming Ma
- Department of Hepatobiliary Surgery, Xinjiang Uygur Autonomous Region People's Hospital, Ürümqi, Xinjiang 830001, P.R. China
| | - Zeliang Zhao
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
| | - Qisan Wang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
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Ciga Lozano MÁ, Codina Cazador A, Ortiz Hurtado H. Resultados oncológicos según el tipo de resección en el tratamiento del cáncer de recto. Cir Esp 2015; 93:229-35. [DOI: 10.1016/j.ciresp.2014.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/21/2014] [Accepted: 06/29/2014] [Indexed: 12/13/2022]
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Liu P, Bao H, Zhang X, Zhang J, Ma L, Wang Y, Li C, Wang Z, Gong P. Better operative outcomes achieved with the prone jackknife vs. lithotomy position during abdominoperineal resection in patients with low rectal cancer. World J Surg Oncol 2015; 13:39. [PMID: 25889121 PMCID: PMC4331390 DOI: 10.1186/s12957-015-0453-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 01/08/2015] [Indexed: 12/21/2022] Open
Abstract
Background Lithotomy (LT) and prone jackknife positions (PJ) are routinely used for abdominoperineal resection (APR). The present study compared the clinical, pathological, and oncological outcomes of PJ-APR vs. LT-APR in low rectal cancer patients in order to confirm which position will provide more benefits to patients undergoing APR. Methods This is a retrospective study of consecutive patients with low rectal cancer who underwent curative APR between January 2002 and December 2011. Patients were matched 1:2 (PJ-APR = 74 and LT-APR = 37 patients) based on gender and age. Perioperative data, postoperative outcomes, and survival were compared between the two approaches. Results Hospital stay was shorter with PJ-APR compared with LT-APR (P < 0.05). Compared with LT-APR, duration of anesthesia (234 ± 50.8 vs. 291 ± 69 min, P = 0.022) and surgery (183 ± 44.8 vs. 234 ± 60 min, P = 0.016) was shorter with PJ-APR, and estimated blood losses were smaller (549 ± 218 vs. 674 ± 350 mL, P < 0.001). Blood transfusions were required in 37.8% of LT-APR patients and in 8.1% of PJ-APR patients (P < 0.001). There was no difference in the distribution of N stages (P = 0.27). Median follow-up was 47.1 (13.6–129.7) months. Postoperative complications were reported by fewer patients after PJ-APR compared with LT-APR (14.9% vs. 32.4%, P = 0.030). There were no significant differences in overall survival, disease-free survival, local recurrence, and distant metastasis (P > 0.05). Conclusions The PJ position provided a better exposure for low rectal cancer and had a lower operative risk and complication rates than LT-APR. However, there was no difference in rectal cancer prognosis between the two approaches. PJ-APR might be a better choice for patients with low rectal cancer.
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Affiliation(s)
- Peng Liu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Haidong Bao
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Xianbin Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Jian Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Li Ma
- Department of Epidemiology, Dalian Medical University, 9 Lvshun Road South, 116044, Dalian, China.
| | - Yulin Wang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Chunyan Li
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Zhongyu Wang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Peng Gong
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
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Wang XT, Li DG, Li L, Kong FB, Pang LM, Mai W. Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer. Pathol Oncol Res 2015; 21:19-27. [PMID: 25430561 PMCID: PMC4287681 DOI: 10.1007/s12253-014-9863-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 10/22/2014] [Indexed: 12/16/2022]
Abstract
In lower rectal cancer, postoperative outcome is still subject of controversy between the advocates of abdominoperineal resection (APR) and low anterior resection (LAR). Reports suggest that low anterior resection may be oncologically superior to abdominoperineal excision, although no good evidence exists to support this. Publications were identified which assessed the differences comparing 5-year survival, local recurrence, circumferential resection margin rate, complications and so on. A meta-analysis was performed to clarify the safety and feasibility of the two procedures with several types of outcome measures. A total of 13 studies met the inclusion criteria, and comprised 6,850 cases. Analysis of these data showed that LAR group was highly correlated with 5-year survival (pooled OR = 1.73, 95%CI: 1.30-2.29, P = 0.0002 random-effect). And local recurrence rate of APR group was significantly higher than that in LAR group (pooled OR = 0.63, 95%CI: 0.53-0.75, P < 0.00001 fixed-effect). Also, the circumferential resection margin (CRM) were high involved in APR group than in LAR group. (5 trials reported the data, pooled OR = 0.43, 95%CI: 0.36-0.52, P < 0.00001 fixed-effect). Besides, the incidents of overall complications of APR group was higher compared with LAR group (pooled OR = 0.52, 95%CI: 0.29-0.92, P = 0.03 random-effect). Patients treated by APR have a higher rate of CRM involvement, a higher local recurrence, and poorer prognosis than LAR. And there is evidence that in selected low rectal cancer patients, LAR can be used safely with a better oncological outcome than APR. due to the inherent limitations of the present study, for example, the trails available for this systematic review are limited and the finite retrospective data, future prospective randomized controlled trials will be useful to fully investigate these outcome measures and to confirm this conclusion.
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Affiliation(s)
- Xiao-Tong Wang
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - De-Gang Li
- Departments of Surgery, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Lei Li
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - Fan-Biao Kong
- Departments of Surgery, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Li-Ming Pang
- Departments of Surgery, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Wei Mai
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
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Gawad W, Fakhr I, Lotayef M, Mansour O, Mokhtar N. Sphincter saving and abdomino-perineal resections following neoadjuvant chemoradiation in locally advanced low rectal cancer. J Egypt Natl Canc Inst 2014; 27:19-24. [PMID: 25496990 DOI: 10.1016/j.jnci.2014.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 11/12/2014] [Accepted: 11/16/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The improvement in surgical techniques alongside neoadjuvant chemoradiation enabled more patients with low rectal cancer to have sphincter preservation. STUDY AIM To compare the oncologic and functional outcome in patients with locally advanced low rectal cancer treated by neoadjuvant chemoradiation followed by sphincter saving resection (SSR) against those who underwent abdomino-perineal resection (APR). PATIENTS AND METHODS A total of 111 patients with low rectal cancer were included in the study. Sixty-one consented patients who prospectively underwent SSR, from Jan 2008 to Jan 2013, and a retrospective group, formed of 50 patients, selected from cases seen at NCI, with comparable demographic, clinical and pathologic criteria, who underwent APR from Jan 2003 to Jan 2008. All lesions were <5 cm from anal verge. All 111 patients received preoperative chemoradiation and total mesorectal excision. RESULTS All tumors were located at a median of 3.6 cm (range 2.5-4.5 cm) for the SSR group, and 3.5 cm (range 2.5-4.6 cm) for the APR group, from the anal verge. The median follow-up was 34 months (range 1-60 months) for both groups. The difference in disease recurrence and OS between the APR and SSR groups were both statistically insignificant. CONCLUSION In low rectal cancer, the sphincter preservation appears to have nearly the same oncologic outcome compared to APR, this might be attributed to the small sample size and short follow up period. However, patients with sphincter preservation have certainly demonstrated an indisputable better functional outcome, in terms of stoma avoidance and adequate continence.
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Affiliation(s)
- W Gawad
- Surgical Oncology Department, National Cancer Institute (NCI), Cairo University, Cairo, Fom-El-Khalig, Egypt
| | - I Fakhr
- Surgical Oncology Department, National Cancer Institute (NCI), Cairo University, Cairo, Fom-El-Khalig, Egypt.
| | - M Lotayef
- Radiation Oncology Department, National Cancer Institute (NCI), Cairo University, Cairo, Fom-El-Khalig, Egypt
| | - O Mansour
- Medical Oncology Department, National Cancer Institute (NCI), Cairo University, Cairo, Fom-El-Khalig, Egypt
| | - N Mokhtar
- Pathology Department, National Cancer Institute (NCI), Cairo University, Cairo, Fom-El-Khalig, Egypt
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Kulu Y, Müller-Stich BP, Bruckner T, Gehrig T, Büchler MW, Bergmann F, Ulrich A. Radical Surgery with Total Mesorectal Excision in Patients with T1 Rectal Cancer. Ann Surg Oncol 2014; 22:2051-8. [DOI: 10.1245/s10434-014-4179-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Indexed: 01/03/2023]
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Wang L, Gu GL, Li ZW, Peng YF, Gu J. Abdominoperineal excision following preoperative radiotherapy for rectal cancer: unfavorable prognosis even with negative circumferential resection margin. World J Gastroenterol 2014; 20:9138-9145. [PMID: 25083087 PMCID: PMC4112869 DOI: 10.3748/wjg.v20.i27.9138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/10/2014] [Accepted: 04/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate whether an abdominoperineal excision (APE) is associated with increased local recurrence (LR) and shortened disease-free survival (DFS) in mid-low rectal cancer with a negative circumferential resection margin (CRM). METHODS 283 consecutive cases of mid-low rectal cancer underwent preoperative 30 Gy/10 F radiotherapy and surgery in Peking University Cancer Hospital between August 2003 and August 2009. Patients with positive CRM and intraoperative distant metastasis were precluded according to exclusion criteria. Survival analyses were performed in patients with APE or non-APE procedures. RESULTS 256 of the 283 (90.5%) cases were enrolled in the analysis, including 78 (30.5%) and 178 (69.5%) cases who received APE and non-APE procedures. Fewer female patients (P = 0.016), lower level of tumor (P = 0.000) and higher body mass index (P = 0.006) were found in the APE group. On univariate analysis, the APE group had a higher LR rate (5.1% vs 1.1%, P = 0.036) and decreased DFS (73.1% vs 83.4%, P = 0.021). On multivariate analysis, APE procedure was also an independent risk factor for LR (HR = 5.960, 1.085-32.728, P = 0.040) and decreased DFS (HR = 2.304, 1.298-4.092, P = 0.004). In stratified analysis for lower rectal cancer, APE procedure was still an independent risk factor for higher LR rate (5.6% vs 0%, P = 0.024) and shortened DFS (91.5% vs 73.6%, P = 0.002). CONCLUSION Following preoperative 30 Gy/10 F radiotherapy, APE procedure was still a predictor for LR and decreased DFS even with negative CRM. More intensive preoperative treatment should be planned for the candidates who are scheduled to receive APE with optimal imaging assessment.
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Abstract
BACKGROUND A surgical teaching and auditing program has been implemented to improve the results of treatment for patients with rectal cancer. OBJECTIVE The aim of this study was to assess the treatment and outcome in patients resected for rectal cancer, focusing on differences relating to the type of resection. DESIGN This was an observational study. SETTINGS The study took place throughout the network of hospitals that compose the National Health Service in Spain. PATIENTS This study included a consecutive cohort of 3355 patients from the Spanish Rectal Cancer Project. The data of patients who were operated on electively, with curative intent, by anterior resection (n = 2333 [69.5%]), abdominoperineal excision (n = 774 [23.1%]), and Hartmann procedure (n = 248 [7.4%]) between March 2006 and May 2010 were analyzed. MAIN OUTCOME MEASURES Clinical, pathologic, and outcome results were analyzed in relation to the type of surgery performed. RESULTS After a median follow-up time of 37 months (interquartile range, 30-48 months), bowel perforations were found to be more common in the Hartmann procedure (12.6%) and abdominoperineal groups (10.1%) than in the anterior resection group (2.3%; p < 0.001). Involvement of the circumferential resection margin was also more common in the Hartmann (16.6%) and abdominoperineal groups (14.3%) than in the anterior resection group (6.6%; p < 0.001). Multivariate analysis showed a negative influence on local recurrence, metastasis, survival for advanced stage, intraoperative perforation, invaded circumferential margin, and Hartmann procedure. However, abdominoperineal excision did not significantly influence local recurrence (HR, 0.945; 95% CI, 0.571-1.563; p = 0.825). LIMITATIONS The main weakness of this study was the voluntary nature of registration in the Spanish Rectal Cancer Project. CONCLUSIONS Although bowel perforation and involvement of the circumferential resection margin were more common after abdominoperineal excision than after anterior resection, this study did not identify abdominoperineal excision as a determinant of local recurrence in the context of 3 years of median follow-up.
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Differences in Circumferential Resection Margin Involvement After Abdominoperineal Excision and Low Anterior Resection No Longer Significant. Ann Surg 2014; 259:1150-5. [DOI: 10.1097/sla.0000000000000225] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 2014; 29:321-7. [PMID: 24385025 DOI: 10.1007/s00384-013-1794-6] [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: 11/03/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively. METHODS An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel-Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI). RESULTS Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23-0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12-0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08-0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses. CONCLUSIONS Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.
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Li DG, Kong FB, Liu CQ, Pang LM. Meta-analysis of oncological outcomes after abdominoperineal resection vslow anterior resection for lower rectal cancer. Shijie Huaren Xiaohua Zazhi 2014; 22:4027. [DOI: 10.11569/wcjd.v22.i26.4027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Jorgensen ML, Young JM, Dobbins TA, Solomon MJ. Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery. Br J Surg 2013; 100:1655-63. [DOI: 10.1002/bjs.9293] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators.
Methods
Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots.
Results
A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15·9 (95 per cent confidence interval (c.i.) 14·2 to 17·6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38·2 (34·6 to 41·8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = −0·55, P = 0·019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2·14, 95 per cent c.i. 1·11 to 4·15).
Conclusion
APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.
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Affiliation(s)
- M L Jorgensen
- Cancer Epidemiology and Services Research, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - J M Young
- Cancer Epidemiology and Services Research, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre, Sydney Local Health District and University of Sydney, Sydney, New South Wales, Australia
| | - T A Dobbins
- Cancer Epidemiology and Services Research, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre, Sydney Local Health District and University of Sydney, Sydney, New South Wales, Australia
- Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia
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Speicher PJ, Ligh C, Scarborough JE, Thacker JK, Mantyh CR, Turley RS, Migaly J. A simple scoring system for risk-stratifying rectal cancer patients prior to radical resection. Tech Coloproctol 2013; 18:459-65. [PMID: 24085640 DOI: 10.1007/s10151-013-1076-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 09/15/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Various predictors of perioperative risk for patients with rectal cancer undergoing radical resection have been well described, but no simple scoring system for surgeons to estimate this risk currently exists. The objective of this study was to develop a system for more accurate preoperative evaluations of competing risks and more informed shared decision-making with patients diagnosed with rectal cancer. METHODS The National Surgical Quality Improvement Program-Participant Use Data File for 2005-2011 was used to retrospectively identify patients undergoing radical resection for rectal cancer. A forward-stepwise multivariable logistic regression model was used to create a dynamic scoring system to preoperatively estimate a patient's risk of major complications. RESULTS A total of 6,847 patients met study inclusion criteria. Thirteen risk factors were identified, and using these predictive variables, a scoring system was derived to stratify major complication risk after radical resection. CONCLUSIONS The risk of a major complication after radical resection for rectal cancer is dependent on multiple preoperative variables. This study provides surgeons with a simple but effective tool for estimating major complication risk in rectal cancer patients prior to radical resection. This risk-stratification score serves as a patient-centered resource for discussing perioperative risks and assisting with the shared decision-making of operative planning.
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Affiliation(s)
- P J Speicher
- Department of Surgery, Duke University Medical Center (DUMC), Box 2817, Durham, NC, 27710, USA,
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Omidvari S, Hamedi SH, Mohammadianpanah M, Razzaghi S, Mosalaei A, Ahmadloo N, Ansari M, Pourahmad S. Comparison of abdominoperineal resection and low anterior resection in lower and middle rectal cancer. J Egypt Natl Canc Inst 2013; 25:151-60. [DOI: 10.1016/j.jnci.2013.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/12/2013] [Accepted: 06/15/2013] [Indexed: 01/23/2023] Open
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Hiranyakas A, da Silva G, Wexner SD, Ho YH, Allende D, Berho M. Factors influencing circumferential resection margin in rectal cancer. Colorectal Dis 2013; 15:298-303. [PMID: 22776435 DOI: 10.1111/j.1463-1318.2012.03179.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Abdominoperineal excision (APR) has been associated with higher circumferential resection margin (CRM) involvement and local recurrence rates than extralevator APR for low rectal cancer. This study aimed to evaluate the CRMs in APR and low anterior resection (LAR) specimens and to identify factors influencing CRM involvement. METHOD All pathological specimens from consecutive patients with rectal cancer who underwent curative resection at the Cleveland Clinic Florida, from January 2000 to July 2010, were reviewed by two pathologists. Demographics, tumour characteristics, operative data, postoperative pathology and Dworak's tumour regression grade were compared between specimens with positive and negative CRMs. RESULTS One-hundred and fifty-four patients underwent curative APR (n = 65) or LAR (n = 69). Mean tumour size was 3.6 cm, and mean distance from the dentate line was 5.4 cm. Nine (6.8%) patients had a positive CRM (n = 6 APR, n = 3 LAR), which was associated with tumour size > 5.9 cm (P = 0.002), a distance of ≤ 2.6 cm from the dentate line (P = 0.013), microvascular invasion (P = 0.009), perineural invasion (P < 0.001), number of positive lymph nodes (P = 0.046) and incomplete total mesorectal excision (TME) (P < 0.001). APR specimens were three times more likely than LAR specimens to have an incomplete mesorectum (9.8%vs 2.9%, P = 0.322). CONCLUSIONS Factors associated with a positive CRM were tumour size > 5.9 cm, a distance of ≤ 2.6 cm from the dentate line, incomplete TME, number of positive nodes and microvascular and perineural invasion. The incidence of a positive CRM was not significantly different between LAR and APR (n = 3 LAR and n = 6 APR).
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Landers M, Savage E, McCarthy G, Fitzpatrick JJ. Self-care strategies for the management of bowel symptoms following sphincter-saving surgery for rectal cancer. Clin J Oncol Nurs 2012; 15:E105-13. [PMID: 22119985 DOI: 10.1188/11.cjon.e105-e113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary aim of this article is to identify the self-care strategies that patients use to manage bowel symptoms experienced following sphincter-saving surgery for rectal cancer. Comparisons will be made with self-care strategies used by patients to manage chronic fecal incontinence and the bowel symptoms associated with other chronic bowel diseases, such as irritable bowel syndrome and inflammatory bowel disease. Published studies and conceptual literature from 2000-2010 were the data sources. Three major themes emerged from the literature reflecting the self-care strategies used by patients to manage bowel symptoms: functional self-care strategies (e.g., taking medication), social activity-related self-care strategies (e.g., planning social events), and alternative self-care strategies (e.g., complementary therapies). An analysis of studies highlighted that, through the process of trial and error, patients learned the strategies that were most effective in the management of their bowel symptoms. Knowledge of such strategies will be beneficial to healthcare professionals when educating patients about effective management of bowel symptoms following sphincter-saving surgery.
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Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 2012; 99:603-12. [PMID: 22246846 DOI: 10.1002/bjs.8677] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer. METHODS A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011. RESULTS Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7. CONCLUSION Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.
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Affiliation(s)
- S T Martin
- Department of Colorectal Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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Chen ZH, Song XM, Chen SC, Li MZ, Li XX, Zhan WH, He YL. Risk factors for adverse outcome in low rectal cancer. World J Gastroenterol 2012; 18:64-9. [PMID: 22228972 PMCID: PMC3251807 DOI: 10.3748/wjg.v18.i1.64] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 07/07/2011] [Accepted: 07/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To demonstrate the oncologic outcomes of low rectal cancer and to clarify the risk factors for survival, focusing particularly on the type of surgery performed.
METHODS: Data from patients with low rectal carcinomas who underwent surgery, either sphincter-preserving surgery (SPS) or abdominoperineal resection (APR), at The First Affiliated Hospital of Sun Yat-sen University in China from August 1994 to December 2005 were retrospectively analyzed.
RESULTS: Of 331 patients with low rectal cancer, 159 (48.0%) were treated with SPS. A higher incidence of positive resection margins and a higher 5-year cumulative local recurrence rate (14.7% vs 6.8%, P = 0.041) were observed in patients after APR compared to SPS. The five-year overall survival (OS) was 54.6% after APR and 66.8% after SPS (P = 0.018), and the 5-year disease-free survival (DFS) was 52.9% after APR and 65.5% after SPS (P = 0.013). In multivariate analysis, poor OS and DFS were significantly related to positive resection margins, pT3-4, and pTNM III-IV but not to the type of surgery.
CONCLUSION: Despite a higher rate of positive resection margins after APR, the type of surgery was not identified as an independent risk factor for survival.
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Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only? Dis Colon Rectum 2012; 55:51-8. [PMID: 22156867 DOI: 10.1097/dcr.0b013e3182351c1f] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous reports suggest that patients with rectal cancer undergoing abdominoperineal resection have worse oncologic outcomes in comparison with those undergoing restorative rectal resection. OBJECTIVE This study aimed to assess factors influencing oncologic outcomes for patients undergoing surgery for rectal cancer. DESIGN This study is a retrospective review of prospectively gathered data. SETTING Data were gathered from a prospective cancer database. PATIENTS Patients were included who underwent radical resection for mid and lower third rectal cancer (1991-2006). MAIN OUTCOME MEASURES The primary outcomes measured were the impact of various factors on perioperative outcomes, local recurrence, and disease-free survival for patients undergoing abdominoperineal resection. RESULTS Four hundred thirteen (29%) patients underwent abdominoperineal resection and 993 (71%) underwent restorative resection for rectal cancer. Patients with abdominoperineal resection were older (p < 0.0001), had a higher mean ASA score (p < 0.001), worse tumor differentiation (p < 0.001), and higher tumor stage (p = 0.0001). Although overall morbidity was lower in the abdominoperineal resection group (p = 0.001), the length of stay was greater (p < 0.001). After a similar period of follow-up (5.2 ± 3.9 vs 5.3 ± 3.4 y, p = 0.58), local recurrence (7% vs 3%, p = 0.02) was higher after abdominoperineal resection, but overall survival (56% vs 71%, p < 0.001) and disease-free survival (54% vs 70%, p < 0.001) were lower. On multivariate analysis, higher stage, poor tumor differentiation, involved margins, and older age were associated with worse survival, whereas higher stage, poor tumor differentiation, and abdominoperineal resection were associated with greater recurrence. These worse oncologic outcomes persisted even when the groups were stratified based on the location of the cancer in mid or distal rectum and for patients with a clear circumferential margin. LIMITATION This study was limited by its retrospective nature. CONCLUSION Technical factors alone are unlikely to be responsible for the worse outcomes after abdominoperineal resection in comparison with restorative resection. A combination of patient- and tumor-related factors that may have indicated the choice of the procedure also probably contribute to the worse outcomes. Because patients undergoing abdominoperineal resection represent a high risk for poor outcomes, management strategies need to consider all these factors during treatment.
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Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer--a systematic overview. Int J Colorectal Dis 2011; 26:1227-40. [PMID: 21603901 DOI: 10.1007/s00384-011-1235-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence. METHODS A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics. RESULTS In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups. CONCLUSION This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.
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Abstract
AIM The review aimed to offer a contemporary perspective of the quality of current colorectal surgery. METHOD A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language. RESULTS Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework. CONCLUSION A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.
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Affiliation(s)
- A M Almoudaris
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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37
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Martijnse IS, Dudink RL, West NP, Wasowicz D, Nieuwenhuijzen GA, van Lijnschoten I, Martijn H, Lemmens VE, van de Velde CJ, Nagtegaal ID, Quirke P, Rutten HJ. Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome. Ann Surg Oncol 2011; 19:786-93. [DOI: 10.1245/s10434-011-2004-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Indexed: 12/13/2022]
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Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection. Dis Colon Rectum 2011; 54:793-802. [PMID: 21654245 DOI: 10.1007/dcr.0b013e318215a1cb] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Suboptimal oncologic outcomes from abdominoperineal resection have been related to high rates of circumferential margin involvement. The extralevator approach has gained popularity as a means of reducing circumferential margin involvement, but it remains unknown whether comparable outcomes are achievable with a conventional approach to abdominoperineal resection. OBJECTIVE This study aimed to determine the rate of circumferential margin involvement, to identify factors predictive for a positive circumferential margin, and to relate these findings to long-term outcomes. DESIGN This is a retrospective analysis of a prospective clinical database. SETTINGS This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS Patients were included who underwent abdominoperineal resection for low rectal adenocarcinoma between 1997 and 2006. MAIN OUTCOME MEASURES The main outcome measures included the rate of circumferential margin involvement, local recurrence, and disease-free survival. RESULTS A total of 115 patients underwent abdominoperineal resection for primary adenocarcinoma of the rectum. A positive circumferential margin was demonstrated in 18 patients (15.7%). Intraoperative perforations occurred in 7 patients (6.1%). Tumors located anteriorly had a higher rate of circumferential margin involvement (31.6%) compared with lateral (13%), posterior (10%), and circumferential tumors (0%) (P = .024). This finding was reflected by a reduced median distance to the circumferential margin in anterior tumors. Curative resections (n = 108) were followed up for a median of 55.5 months. The 5-year local recurrence rate was 10.6% and the 5-year disease-free survival was 67.4%. Cox regression analysis revealed that circumferential margin involvement was an independent predictor for local recurrence; and T-category, N-category, and circumferential margin involvement for disease-free survival. LIMITATIONS This study was limited by its sample size and the number of outcome events. CONCLUSIONS The conventional approach to abdominoperineal resection can produce oncologic outcomes comparable to the extralevator approach. However, the rate of circumferential margin involvement is higher than in restorative procedures and may be related to difficulties in obtaining adequate clearance in anterior tumors.
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Stelzner S, Hellmich G, Schubert C, Puffer E, Haroske G, Witzigmann H. Short-term outcome of extra-levator abdominoperineal excision for rectal cancer. Int J Colorectal Dis 2011; 26:919-25. [PMID: 21350936 DOI: 10.1007/s00384-011-1157-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Extra-levator abdominoperineal excision (ELAPE) has been introduced to avoid oncologic problems encountered with conventional abdominoperineal excision (APE) such as high rates of inadvertent bowel perforation and of positive circumferential resection margin. We compare our short-term results of this new approach with a historic patient cohort. PATIENTS AND METHODS From 1997 until 2010, we performed 46 consecutive conventional APE and 28 ELAPE after neoadjuvant therapy with a macroscopically complete resection in the true pelvis. Patient data was prospectively collected in our colorectal tumor database. Patient and tumor characteristics were compared as were the rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses. RESULTS The rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses were 15.2% vs. 0 (p = 0.04), 4.9% vs. 0 (p = 0.511), and 17.4% vs. 10.7% (p = 0.518), respectively, in the conventional APE vs. ELAPE group. CONCLUSION With a significant reduction of the bowel perforation rate and a reduction of circumferential margin involvement and wound abscess formation, ELAPE improves important surrogate parameters for local recurrence rate and survival.
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Affiliation(s)
- Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany.
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How P, Shihab O, Tekkis P, Brown G, Quirke P, Heald R, Moran B. A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era. Surg Oncol 2011; 20:e149-55. [PMID: 21632237 DOI: 10.1016/j.suronc.2011.05.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/04/2011] [Accepted: 05/05/2011] [Indexed: 01/29/2023]
Abstract
PURPOSE It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE. METHODS A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected. RESULTS Twenty four studies fulfilled the eligibility criteria with Newcastle-Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE. CONCLUSIONS Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced.
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Affiliation(s)
- P How
- Pelican Cancer Foundation, The Ark, Dinwoodie Drive, Basingstoke, RG24 9NN, UK.
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Mulsow J, Winter DC. Sphincter preservation for distal rectal cancer - a goal worth achieving at all costs? World J Gastroenterol 2011; 17:855-61. [PMID: 21412495 PMCID: PMC3051136 DOI: 10.3748/wjg.v17.i7.855] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/18/2011] [Accepted: 01/25/2011] [Indexed: 02/06/2023] Open
Abstract
To assess the merits of currently available treatment options in the management of patients with low rectal cancer, a review of the medical literature pertaining to the operative and non-operative management of low rectal cancer was performed, with particular emphasis on sphincter preservation, oncological outcome, functional outcome, morbidity, quality of life, and patient preference. Low anterior resection (AR) is technically feasible in an increasing proportion of patients with low rectal cancer. The cost of sphincter preservation is the risk of morbidity and poor functional outcome in a significant proportion of patients. Transanal and endoscopic surgery are attractive options in selected patients that can provide satisfactory oncological outcomes while avoiding the morbidity and functional sequelae of open total mesorectal excision. In complete responders to neo-adjuvant chemoradiotherapy, a non-operative approach may prove to be an option. Abdominoperineal excision (APE) imposes a permanent stoma and is associated with significant incidence of perineal morbidity but avoids the risk of poor functional outcome following AR. Quality of life following AR and APE is comparable. Given the choice, most patients will choose AR over APE, however patients following APE positively appraise this option. In striving toward sphincter preservation the challenge is not only to achieve the best possible oncological outcome, but also to ensure that patients with low rectal cancer have realistic and accurate expectations of their treatment choice so that the best possible overall outcome can be obtained by each individual.
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Silberfein EJ, Kattepogu KM, Hu CY, Skibber JM, Rodriguez-Bigas MA, Feig B, Das P, Krishnan S, Crane C, Kopetz S, Eng C, Chang GJ. Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol 2010; 17:2863-9. [PMID: 20552409 PMCID: PMC3071558 DOI: 10.1245/s10434-010-1119-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of distal rectal cancer remains clinically challenging and includes proctectomy and coloanal anastomosis (CAA) or abdominoperineal resection (APR). The purpose of this study is to evaluate operative and pathologic factors associated with long-term survival and local recurrence outcomes in patients treated for distal rectal cancer. METHODS A retrospective consecutive cohort study of 304 patients treated for distal rectal cancer with radical resection from 1993 to 2003 was performed. Patients were grouped by procedure (CAA or APR). Demographic, pathologic, recurrence, and survival data were analyzed utilizing chi-square analysis for comparison of proportions. Survival analysis was performed using Kaplan-Meier method and log-rank test for univariate and Cox regression for multivariate comparison. RESULTS The median tumor distance from the anal verge was 2 cm [interquartile range (IQR) 0.5-4 cm]. Margins were negative in all but four patients (one distal, 0.3%; three radial, 1%). The 5-year overall survival rate was 82% (88.6% stage pI, 80.5% stage pII, 67.9% stage pIII). Older age, advanced pathologic stage, presence of lymphovascular or perineural invasion, earlier treatment period, and APR surgery type were associated with worse survival on multivariate analysis. The 5-year local recurrence rate was 5.3% after CAA and 7.9% after APR (p = 0.33). CONCLUSIONS Low rates of local recurrence and good overall survival can be achieved after treatment of distal rectal cancer with stage-appropriate chemoradiation and proctectomy with CAA or APR. Sphincter preservation can be achieved even with distal margins less than 2 cm.
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Affiliation(s)
- Eric J Silberfein
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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van Dijk TH, Wiggers T, Havenga K. Abdominoperineal Resections for Rectal Cancer: Reducing the Risk of Local Recurrence. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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West NP, Anderin C, Smith KJE, Holm T, Quirke P. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 2010; 97:588-99. [DOI: 10.1002/bjs.6916] [Citation(s) in RCA: 319] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Abdominoperineal excision (APE) for low rectal cancer is associated with higher rates of circumferential resection margin (CRM) involvement and intraoperative perforation (IOPs) than anterior resection for higher tumours. This multicentre observational study was designed to confirm that extralevator APE can improve outcomes and investigated the morbidity associated with such extensive surgery.
Methods
Some 176 extralevator APE procedures from 11 European colorectal surgeons were compared with 124 standard excisions from one UK centre. Clinical and pathological data were collected along with specimen photographs. Tissue morphometry was performed on the distal ten slices of the excision.
Results
Extralevator APE removed more tissue from outside the smooth muscle layer per slice (median area 2120 versus 1259 mm2; P < 0·001) leading to a reduction in CRM involvement (from 49·6 to 20·3 per cent; P < 0·001) and IOP (from 28·2 to 8·2 per cent; P < 0·001) compared with standard surgery. However, extralevator surgery was associated with an increase in perineal wound complications (from 20 to 38·0 per cent; P = 0·019).
Conclusion
Extralevator APE is associated with less CRM involvement and IOP than standard surgery.
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Affiliation(s)
- N P West
- Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, UK
| | - C Anderin
- Department of Colorectal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - K J E Smith
- John Goligher Colorectal Unit, Leeds General Infirmary, Leeds, UK
| | - T Holm
- Department of Colorectal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - P Quirke
- Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, UK
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45
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Kim JS, Hur H, Kim NK, Kim YW, Cho SY, Kim JY, Min BS, Ahn JB, Keum KC, Kim H, Sohn SK, Cho CH. Oncologic outcomes after radical surgery following preoperative chemoradiotherapy for locally advanced lower rectal cancer: abdominoperineal resection versus sphincter-preserving procedure. Ann Surg Oncol 2009; 16:1266-73. [PMID: 19224287 DOI: 10.1245/s10434-009-0338-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 12/22/2008] [Accepted: 12/23/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer. METHODS A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6-8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated. RESULTS Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival. CONCLUSIONS Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.
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Affiliation(s)
- Jin Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Bozzetti F. Cancer of the Rectum: Abdominoperineal and Sphincter-Saving Resections. COLORECTAL CANCER 2009. [DOI: 10.1007/978-1-4020-9545-0_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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de Chaisemartin C, Penna C, Goere D, Benoist S, Beauchet A, Julie C, Nordlinger B. Presentation and prognosis of local recurrence after total mesorectal excision. Colorectal Dis 2009; 11:60-6. [PMID: 18462223 DOI: 10.1111/j.1463-1318.2008.01537.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to describe the presentation, treatment and prognosis of local recurrences following total mesorectal excision for rectal adenocarcinoma. METHOD Between 1999 and 2002, 201 patients were treated with total mesorectal excision for mid or low rectal cancer and were followed up prospectively. RESULTS Overall 2-year survival was 85%. The 2-year recurrence rate was 8%. Eighteen patients developed local recurrence at 3-60 months. Nine recurrences originated from the pelvic sidewall. These recurrences were symptomatic in 90% of patients. Only two patients were reoperated with a R0 resection and were alive without local recurrence after 19 and 31 months. The seven others died within 9 months. Nine recurrences originated from an anastomotic suture line. Only two had symptoms. A R0 surgical resection was performed in all patients with a 67% sphincter conservation rate. After 26-months of median follow-up (range 7-58), all patients were alive. CONCLUSION Half of the local recurrence after total mesorectal excision was located at the anastomotic site. Rectoscopic examination should be performed regularly to detect these anatomotic recurrences that are accessible to a R0 itérative resection.
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Affiliation(s)
- C de Chaisemartin
- Department of Surgery, AP-HP, Hôpital Ambroise Paré, Boulogne, France
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Frileux P, Burdy G, Aegerter P, Dubost G, Bernier M, Mabro M, Caillard C, Dubrez J, Brams A. Surgical treatment of rectal cancer: results of a strategy for selective preoperative radiotherapy. ACTA ACUST UNITED AC 2008; 31:934-40. [PMID: 18166881 DOI: 10.1016/s0399-8320(07)78301-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIM The indications for preoperative adjuvant therapy in rectal cancer are still a subject of debate. The objective of this study was to analyze the results of surgical resection and selective radiotherapy in a group of high-risk patients (Dukes B and C) taken from a series of 148 consecutive patients with rectal cancer. METHODS All patients with rectal cancer considered for resection during the period 1994-2004 were prospectively included. The policy was to deliver preoperative radiotherapy in cases of fixed or tethered tumors or when imaging predicted T3 tumors with positive circumferential margins. Other tumors were resected without neoadjuvant therapy. All resections were done using the total mesorectal excision (TME) technique. RESULTS One hundred and forty-eight consecutive patients underwent rectal resection during the study period. A sphincter-saving technique was carried out in 134 patients (90%). No patient was excluded from the analysis. The perioperative mortality was 2/148 (1.5%). Curative surgery was obtained in 135 patients. The 94 patients with a Dukes B or C tumor formed the high-risk group that was the basis of our study. The mean follow-up in this group was 58 months (range 24-120). Twenty patients (21%) received preoperative radiotherapy (PRT) and 74 (79%) underwent surgical resection alone. A positive circumferential margin, defined as one that was < or =1 mm, was found in seven of the 85 patients (8.2%) for whom this measure was available. The actuarial five-year overall survival was 74%. Local recurrence developed in eight patients (8.4%): four in the PRT group (20%), and four in the non-PRT group (5.4%). Only two patients developed an isolated local recurrence. CONCLUSIONS Preoperative adjuvant therapy can be safely omitted in patients who demonstrate clear circumferential margins on preoperative imaging, provided that adequate surgery is subsequently performed.
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Affiliation(s)
- Pascal Frileux
- Service de chirurgie digestive, Hôpital Foch, Suresnes Cedex.
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Huh JW, Jung EJ, Park YA, Lee KY, Sohn SK. Sphincter-Preserving Operations Following Preoperative Chemoradiation: An Alternative to Abdominoperineal Resection for Lower Rectal Cancer? World J Surg 2008; 32:1116-23. [DOI: 10.1007/s00268-008-9520-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE To assess rates of abdominoperineal excision of the rectum (APER) for rectal cancer between centers and over time, and to evaluate the influence of patient characteristics, including social deprivation, on APER rate. METHODS Data on patients undergoing APER or anterior resection (AR) in England were extracted from a national administrative database for the years 1996 to 2004. The primary outcome was the proportion of patients presenting with rectal cancer undergoing APER. Hierarchical logistic regression was used to identify independent factors associated with a nonrestorative resection. RESULTS Data on 52,643 patients were analyzed, 13,109(24.9%) of whom underwent APER. The APER rate significantly reduced over the study period from 29.4% to 21.2% (P < 0.001). Operative mortality following AR decreased significantly during the period of study (5.1% to 4.2%, P = 0.002), while that following APER did not (P = 0.075). Male patients were more likely to undergo APER (P < 0.001), whereas those with an emergency presentation more commonly underwent AR (P < 0.001). Independent predictors of increased APER rate were male gender (odds ratio [OR] = 1.239, P < 0.001) and social deprivation (most vs. least deprived; OR = 1.589, P < 0.001), whereas increasing patient age (OR = 0.977, P = 0.027 per 10-year increase), year of study (2003/4 vs. 1996/7; OR = 0.646, P < 0.001) and initial presentation as an emergency (OR = 0.713, P < 0.001) were associated with lower APER rates. After accounting for case-mix, there was significant between-center variability in APER rates. CONCLUSION Socially deprived patients were more likely to undergo abdominoperineal resection. Significant improvements in rates of nonrestorative resection were seen over time but although short-term outcomes following AR have improved, those following APER have not. Permanent stoma rates following rectal cancer surgery may be considered a surrogate marker of surgical quality.
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