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Matsuda T, Yamashita K, Hasegawa H, Sawada R, Koterazawa Y, Harada H, Urakawa N, Goto H, Kanaji S, Kakeji Y. Efficacy and long-term outcomes of abdominoperineal resection using transperineal total mesorectal excision approach for rectal cancer. Surg Today 2025; 55:579-587. [PMID: 39287627 DOI: 10.1007/s00595-024-02937-4] [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: 08/05/2024] [Accepted: 08/26/2024] [Indexed: 09/19/2024]
Abstract
PURPOSE Although abdominoperineal resection (APR) is essential for a certain population of patients with low rectal cancer, it is technically difficult and sometimes contains oncological disadvantages. Thus, the use of the transperineal total mesorectal excision (TpTME) approach might overcome such concerns regarding APR. METHODS In total, 27 patients who underwent conventional APR (conventional group) and 49 patients who underwent APR using the TpTME approach (TpTME group) for low rectal cancer were included. After propensity score matching, the outcomes of the 25 matched cases were compared between groups. RESULTS The operative time was significantly shorter in the TpTME group than in the conventional group (452 vs. 565 min, P = 0.039). Intraoperative blood loss and transfusion rates were also significantly lower in the TpTME group than in the conventional group (25 mL vs. 200 mL, P < 0.001 and 0% vs. 28.0%, P = 0.015, respectively). Although the incidence of postoperative complications did not differ significantly, the postoperative hospital stay was significantly shorter in the TpTME group than in the conventional group (24 vs. 36 days, P = 0.001). The 5 year relapse-free survival rates in the TpTME and conventional groups were 62.0% and 57.6%, respectively (P = 0.648). CONCLUSION APR using the TpTME approach for the treatment of low rectal cancer is feasible and can achieve favorable oncological outcomes.
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Affiliation(s)
- Takeru Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
- Division of Minimally Invasive Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Chuo-ku, Kobe, 650-0017, Japan.
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryuichiro Sawada
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasufumi Koterazawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hitoshi Harada
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hironobu Goto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Hamada M, Matsumi Y, Inada R, Matsumoto T, Kita M, Boku S, Kurokawa H, Tsuta K. MRI navigation surgery for T4b rectal cancer using multiple minimally invasive surgical approaches. Int J Colorectal Dis 2025; 40:66. [PMID: 40085244 PMCID: PMC11909045 DOI: 10.1007/s00384-025-04838-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2025] [Indexed: 03/16/2025]
Abstract
BACKGROUND These days, various surgical techniques such as trans-anal, trans-perineal total mesorectal excision, and transvaginal natural orifice transluminal endoscopic surgery have been utilized with flexibility, which was not possible before the laparoscopic era. METHODS From January 2014 to January 2023, 40 cases of c(yc)T4b rectal cancer underwent local curative surgery laparoscopically at Kansai Medical University Hospital. In 25 consecutive cases, we adopted multiple approaches (trans-anal total mesorectal excision, transvaginal natural orifice transluminal endoscopic surgery, trans-perineal total mesorectal excision, or prone position first abdominoperineal excision) to remove the deepest part of the tumor indicated by MRI last as the specimen-oriented surgery. The remaining 15 patients underwent top-to-bottom surgery based on standard surgery. The primary endpoint was the local recurrence rate of the specimen-oriented surgery group compared to that of the standard surgery group. RESULTS The specimen-oriented surgery group had a median follow-up of 3.9 (0.4-7.4) years with no local recurrence, while the standard surgery group had a median follow-up of 1.5 (0.7-3.7) years with 5 of 15 patients (33%) experiencing more local recurrence than specimen-oriented surgery group (p = 0.005). Comparison of the local recurrence ( +) and ( -) groups showed significant differences in pCRM positive rate, neoadjuvant therapy, tumor size, and approach (specimen-oriented surgery vs. standard surgery) in univariate analysis (p < 0.05). Still, no significant differences were found in the multivariate analysis. CONCLUSIONS In the laparoscopic setting, local cure of c(yc)T4b rectal cancer requires a different strategy than open surgery, and specimen-oriented surgery may be a promising procedure.
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Affiliation(s)
- Madoka Hamada
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, 2-3-1, Shinmachi, Hirakata, Osaka, 573-1191, Japan.
| | - Yuki Matsumi
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, 2-3-1, Shinmachi, Hirakata, Osaka, 573-1191, Japan
| | - Ryo Inada
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, 2-3-1, Shinmachi, Hirakata, Osaka, 573-1191, Japan
| | - Tomoko Matsumoto
- Department of Gastrointestinal Surgery, Kansai Medical University Hospital, 2-3-1, Shinmachi, Hirakata, Osaka, 573-1191, Japan
| | - Masato Kita
- Department of Obstetrics and Gynecology, Kansai Medical University Hospital, Hirakata, Japan
| | - Shogen Boku
- Cancer Treatment Center, Kansai Medical University Hospital, Hirakata, Japan
| | - Hiroaki Kurokawa
- Department of Radiology, Kansai Medical University Hospital, Hirakata, Japan
| | - Koji Tsuta
- Department of Pathology, Kansai Medical University Hospital, Hirakata, Japan
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Kawada K, Inamura Y, Morikawa A, Matsuoka H, Yokota M, Obama K, Kawamoto K. Perineal-First Approach in Robotic Abdominoperineal Resection. Ann Surg Oncol 2024; 31:7820-7821. [PMID: 39266793 DOI: 10.1245/s10434-024-16166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 08/23/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Although abdominoperineal resection (APR) is required for rectal cancer invading the levator ani muscle, its curative outcomes remain poorer than those of other rectal surgeries.1-3 In particular, the anatomic complexity around the anterior wall of the rectum increases the technical difficulty during APR, resulting in a high frequency of margin involvement that causes local recurrence. In this video, we present the technical details of a robotic perineal-first APR approach. METHODS For a 46 year-old man, locally advanced rectal cancer invading the levator ani muscles was diagnosed. Although total neoadjuvant therapy (8 cycles of induction FOLFOXIRI followed by chemoradiotherapy 50.4 Gy) decreased the tumor size, invasion was suspected still to remain. Therefore, robotic APR was performed. Written informed consent was obtained from the patient. For the perineal-first approach, we created a circular incision around the anus, then divided the fat tissues of the ischiorectal fossa until the levator ani muscle was exposed on both sides. Posterior and anterior dissections were performed along the coccyx and external anal sphincter, respectively. After placement of a lap protector to maintain air-tightness, the robotic approach was initiated. Posterior dissection was performed along the coccyx, then was connected to the already-dissected space created earlier by the perineal approach. Next, the levator ani muscle was divided from the dorsal to the lateral side. Finally, anterior dissection was performed along the prostate, followed by division of the rectourethral muscle, the smooth muscle fibers running vertically. The creation of the already-dissected space on the perineal side offers advantages of robotic manipulation from the abdominal side, especially anterior dissection. RESULTS We performed robotic APR using the perineal-first approach for 17 consecutive patients (12 men and 5 women) between 2019 and 2023. All 17 patients achieved complete total mesorectal excision with negative margins. The mean time required for the perineal approach was about 25 min. In anterior dissection using the robotic approach, division of the smooth muscle fibers at the perineal body (i.e., rectourethral muscle in males4 or muscular intermingling in females5) was reproducibly performed in both males and females. CONCLUSION Robotic APR with a perineal-first approach can be advantageous in ensuring surgical margin safety (especially for the anterior aspect of the rectum).
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Affiliation(s)
- Kenji Kawada
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
| | - Yukio Inamura
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Akitaka Morikawa
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Hiroya Matsuoka
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Mitsuru Yokota
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Kazutaka Obama
- Department of Gastrointestinal Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuyuki Kawamoto
- Department of Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
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Kondo A, Fuke T, Kumamoto K, Asano E, Feng D, Kobara H, Okano K. Transperineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer could improve short-term outcomes: A single-institution retrospective cohort study. Langenbecks Arch Surg 2024; 409:297. [PMID: 39365469 DOI: 10.1007/s00423-024-03493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 09/29/2024] [Indexed: 10/05/2024]
Abstract
PURPOSE Transperineal minimally invasive surgery (TpMIS) during laparoscopic abdominoperineal resection (APR) is an emerging approach that allows for the precise treatment of lower rectal cancer. However, evidence regarding the efficacy of TpMIS is insufficient. This study evaluated the efficacy of TpMIS during laparoscopic APR for patients with lower rectal cancer. METHODS Patients who underwent laparoscopic APR with TpMIS (TpMIS group; n = 12) and those who underwent conventional laparoscopic APR for low rectal cancer (conventional group; n = 13) were enrolled consecutively in this retrospective study. Standardized TpMIS was performed at our institution. Patient and tumor characteristics and intraoperative, postoperative, and pathological outcomes were compared between groups. The primary outcome was postoperative perineal wound infection. RESULTS No patients in the TpMIS group experienced postoperative perineal wound infection; however, five (38.5%) patients in the conventional group experienced postoperative perineal wound infection (significant difference; p = 0.016). The estimated blood loss (median, 81 mL vs. 463 mL) and incidence of postoperative urinary dysfunction (8.3% vs. 46.1%) were significantly lower in the TpMIS group than in the conventional group. The postoperative hospital stay (median, 13 vs. 20 days) of the TpMIS group was significantly shorter than that of the conventional group. Pathological outcomes did not differ between groups. The positive circumferential resection margin rates of the TpMIS and conventional groups were 8.3% and 15.4%, respectively. CONCLUSION TpMIS during laparoscopic APR was associated with significant improvements in the postoperative outcomes of patients with low rectal cancer.
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Affiliation(s)
- Akihiro Kondo
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan.
| | - Takuro Fuke
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Kensuke Kumamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Eisuke Asano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Dongping Feng
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Kagawa University, Kagawa, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
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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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Yeo I, Yoo MW, Park SJ, Moon SK. [Postoperative Imaging Findings of Colorectal Surgery: A Pictorial Essay]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:727-745. [PMID: 39130784 PMCID: PMC11310425 DOI: 10.3348/jksr.2021.0004n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/29/2023] [Accepted: 12/20/2023] [Indexed: 08/13/2024]
Abstract
Postoperative colorectal imaging studies play an important role in the detection of surgical complications and disease recurrence. In this pictorial essay, we briefly describe methods of surgery, imaging findings of their early and late complications, and postsurgical recurrence of cancer and inflammatory bowel disease.
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Du Q, Yang W, Zhang J, Qiu S, Liu X, Wang Y, Yang L, Zhou Z. Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:2338-2348. [PMID: 36928167 PMCID: PMC11020000 DOI: 10.1097/js9.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 11/20/2022] [Indexed: 03/18/2023]
Abstract
BACKGROUND The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis. MATERIALS AND METHODS A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated. RESULTS A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR. CONCLUSIONS Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
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Affiliation(s)
- Qiang Du
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Wenming Yang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Jianhao Zhang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Siyuan Qiu
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Xueting Liu
- Department of Evidence-Based Medicine and Clinical Epidemiology
| | - Yong Wang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Lie Yang
- Department of General Surgery, Division of Gastrointestinal Surgery
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zongguang Zhou
- Department of General Surgery, Division of Gastrointestinal Surgery
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Stotland P, Caycedo-Marulanda A. Response to May and Bethune Comment on 'Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: a word of caution from a multicentric Canadian cohort study'. Colorectal Dis 2024; 26:802-803. [PMID: 38379133 DOI: 10.1111/codi.16920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/06/2023] [Indexed: 02/22/2024]
Affiliation(s)
- Peter Stotland
- North York General Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Antonio Caycedo-Marulanda
- Queen's University, Kingston, Ontario, Canada
- Orlando Health Colon and Rectal Institute, Orlando, Florida, USA
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Salega A, Münch M, Renner P, Thon KP, Steurer W, Mönch D, Koch J, Maaß A, Schlitt HJ, Dahlke MH, Leibold T. Late Local Recurrence after Neoadjuvant Therapy and Radical Resection for Locally Advanced Rectal Cancer. Cancers (Basel) 2024; 16:448. [PMID: 38275889 PMCID: PMC10814985 DOI: 10.3390/cancers16020448] [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: 12/01/2023] [Revised: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Neoadjuvant radiochemotherapy (RCT) and lately total neoadjuvant therapy (TNT) improved local recurrence rates of rectal cancer significantly compared to total mesorectal excision (TME) alone. Yet the occurrence and impact of late local recurrences after many years appears to be a distinct biological problem. We included n = 188 patients with rectal cancer after RCT and radical resection in this study; n = 38 of which had recurrent disease (sites: local (8.0%), liver (6.4%), lung (3.7%)). We found that 68% of all recurrences developed within the first two years. Four patients, however, experience recurrence >8 years after surgery. Here, we report and characterize four cases of late local recurrence (10% of patients with recurrent disease), suggesting that neoadjuvant therapy in principle delays local recurrence.
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Affiliation(s)
- Adrian Salega
- Robert Bosch Centre for Tumour Diseases (RBCT), Department of General and Visceral Surgery, Robert-Bosch-Hospital, 70376 Stuttgart, Germany; (A.S.); (M.M.); (P.R.); (K.-P.T.); (M.-H.D.)
| | - Marina Münch
- Robert Bosch Centre for Tumour Diseases (RBCT), Department of General and Visceral Surgery, Robert-Bosch-Hospital, 70376 Stuttgart, Germany; (A.S.); (M.M.); (P.R.); (K.-P.T.); (M.-H.D.)
| | - Philipp Renner
- Robert Bosch Centre for Tumour Diseases (RBCT), Department of General and Visceral Surgery, Robert-Bosch-Hospital, 70376 Stuttgart, Germany; (A.S.); (M.M.); (P.R.); (K.-P.T.); (M.-H.D.)
| | - Klaus-Peter Thon
- Robert Bosch Centre for Tumour Diseases (RBCT), Department of General and Visceral Surgery, Robert-Bosch-Hospital, 70376 Stuttgart, Germany; (A.S.); (M.M.); (P.R.); (K.-P.T.); (M.-H.D.)
| | - Wolfgang Steurer
- Department of Surgery, Klinikverbund Südwest, Krankenhaus Leonberg, 71229 Leonberg, Germany;
| | - Dina Mönch
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany; (D.M.); (J.K.); (A.M.)
- University of Tübingen, 72074 Tübingen, Germany
| | - Jana Koch
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany; (D.M.); (J.K.); (A.M.)
- University of Tübingen, 72074 Tübingen, Germany
| | - Annika Maaß
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, 70376 Stuttgart, Germany; (D.M.); (J.K.); (A.M.)
- University of Tübingen, 72074 Tübingen, Germany
| | - Hans Jürgen Schlitt
- Department of Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Marc-Hendrik Dahlke
- Robert Bosch Centre for Tumour Diseases (RBCT), Department of General and Visceral Surgery, Robert-Bosch-Hospital, 70376 Stuttgart, Germany; (A.S.); (M.M.); (P.R.); (K.-P.T.); (M.-H.D.)
| | - Tobias Leibold
- Robert Bosch Centre for Tumour Diseases (RBCT), Department of General and Visceral Surgery, Robert-Bosch-Hospital, 70376 Stuttgart, Germany; (A.S.); (M.M.); (P.R.); (K.-P.T.); (M.-H.D.)
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Janczak J, Ukegjini K, Bischofberger S, Turina M, Müller PC, Steffen T. Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review. Cancers (Basel) 2023; 16:26. [PMID: 38201454 PMCID: PMC10778098 DOI: 10.3390/cancers16010026] [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: 11/07/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time. METHODS Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data. RESULTS A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles). CONCLUSION Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.
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Affiliation(s)
- Joanna Janczak
- Clinic for General and Visceral Surgery, Hospital for the Region Fürstenland Toggenburg, CH-9500 Wil, Switzerland;
| | - Kristjan Ukegjini
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Stephan Bischofberger
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
| | - Matthias Turina
- Department of Surgery and Transplantation, University Hospital Zurich, CH-8091 Zurich, Switzerland;
| | - Philip C. Müller
- Department of Surgery, Clarunis—University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, CH-4002 Basel, Switzerland;
| | - Thomas Steffen
- Department of Surgery, Hospital of the Canton of St. Gallen, CH-9007 St. Gallen, Switzerland; (K.U.); (S.B.)
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11
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Manisundaram N, DiBrito SR, Hu CY, Kim Y, Wick E, Palis B, Peacock O, Chang GJ. Reporting of Circumferential Resection Margin in Rectal Cancer Surgery. JAMA Surg 2023; 158:1195-1202. [PMID: 37728906 PMCID: PMC10512166 DOI: 10.1001/jamasurg.2023.4221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/04/2023] [Indexed: 09/22/2023]
Abstract
Importance Circumferential resection margin (CRM) in rectal cancer surgery is a major prognostic indicator associated with local recurrence and overall survival. Facility rates of CRM positivity have recently been established as a new quality measure by the Commission on Cancer (CoC); however, the completeness of CRM status reporting is not well characterized. Objective To describe the changes in CRM reporting and factors associated with low rates of reporting. Design, Setting, and Participants A retrospective cohort study was conducted using data from the National Cancer Database between January 2010 and December 2019. Data were analyzed between October 1, 2021, and February 1, 2022. Data from the National Cancer Database included patients diagnosed with nonmetastatic rectal adenocarcinoma receiving surgical treatment at CoC-accredited facilities throughout the US. Exposures Patient, tumor, and facility-level factors. Facilities were divided by surgical volume, safety-net status, and CoC facility type. Main Outcomes and Measures Circumferential resection margin missingness rates. Results A total of 110 571 patients (59.3% men) with rectal adenocarcinoma who underwent curative-intent surgery at 1307 CoC-accredited hospitals were included for analysis. Reporting of CRM improved over the study period, with a mean (SE) missing 12.0% (0.32%) decreased from 16.3% (0.36%). Academic facilities had a higher missingness than other facility types (14.3% vs 10.5%-12.7%; P < .001). Mean (SE) rates of missingness were similar between hospitals of varying volume (lowest quartile: 12.2% [0.93%] vs highest quartile: 12.4% [0.53%]; P = .96). Cases in which fewer than 12 lymph nodes were removed had higher rates of missingness (18.1% vs 11.4%; P < .001). Increased odds of CRM missingness were noted with T category (odds ratio [OR], 1.50; 95% CI, 1.35-1.65) and N category (OR, 2.00; 95% CI, 1.82-2.20). Black race was associated with missingness (OR, 1.13; 95% CI, 1.06-1.14). Conclusion and Relevance Although CRM positivity reporting has improved over the last decade, the findings of this study suggest there is substantial room for improvement as it becomes a quality standard. Missingness appears to be associated with poor performance on other quality metrics and facility type. This measure appears to be ideal for targeted institution-level feedback to improve quality of care nationally.
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Affiliation(s)
- Naveen Manisundaram
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Chung-Yuan Hu
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Youngwan Kim
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth Wick
- Department of Surgery, The University of California, San Francisco
| | - Bryan Palis
- The American College of Surgeons and the National Cancer Database
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - George J. Chang
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
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12
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Xiao B, Yu J, Ding PR. Nonoperative Management of dMMR/MSI-H Colorectal Cancer following Neoadjuvant Immunotherapy: A Narrative Review. Clin Colon Rectal Surg 2023; 36:378-384. [PMID: 37795463 PMCID: PMC10547541 DOI: 10.1055/s-0043-1767703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Immunotherapy with PD-1 blockade has achieved a great success in colorectal cancers (CRCs) with high microsatellite instability (MSI-H) and deficient mismatch repair (dMMR), and has become the first-line therapy in metastatic setting. Studies of neoadjuvant immunotherapy also report exciting results, showing high rates of clinical complete response (cCR) and pathological complete response. The high efficacy and long duration of response of immunotherapy has prompt attempts to adopt watch-and-wait strategy for patients achieving cCR following the treatment. Thankfully, the watch-and-wait approach has been proposed for nearly 20 years for patients undergoing chemoradiotherapy and has gained ground among patients as well as clinicians. In this narrative review, we combed through the available information on immunotherapy for CRC and on the watch-and-wait strategy in chemoradiotherapy, and looked forward to a future where neoadjuvant immunotherapy as a curative therapy would play a big part in the treatment of MSI-H/dMMR CRC.
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Affiliation(s)
- Binyi Xiao
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Jiehai Yu
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
| | - Pei-Rong Ding
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, P. R. China
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13
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Thiel JT, Welskopf HL, Yurttas C, Farzaliyev F, Daigeler A, Bachmann R. Feasibility of Perineal Defect Reconstruction with Simplified Fasciocutaneous Inferior Gluteal Artery Perforator (IGAP) Flaps after Tumor Resection of the Lower Rectum: Incidence and Outcome in an Interdisciplinary Approach. Cancers (Basel) 2023; 15:3345. [PMID: 37444455 DOI: 10.3390/cancers15133345] [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: 04/02/2023] [Revised: 05/29/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Extralevator abdominoperineal excision (ELAPE) is a relatively new surgical technique for low rectal cancers, enabling a more radical approach than conventional abdominoperineal excision (APE) with a potentially better oncological outcome. To date, no standard exists for reconstruction after extended or extralevator approaches of abdominoperineal (ELAPE) resection for lower gastrointestinal cancer or inflammatory tumors. In the recent literature, techniques with myocutaneous flaps, such as the VY gluteal flap, the pedicled gracilis flap, or the pedicled rectus abdominis flaps (VRAM) are primarily described. We propose a tailored concept with the use of bilateral adipo-fasciocutaneous inferior gluteal artery perforator (IGAP) advancement flaps in VY fashion after ELAPE surgery procedures. This retrospective cohort study analyzes the feasibility of this concept and is, to our knowledge, one of the largest published series of IGAP flaps in the context of primary closure after ELAPE procedures. METHODS In a retrospective cohort analysis, we evaluated all the consecutive patients with rectal resections from Jan 2017 to Sep 2021. All the patients with abdominoperineal resection were included in the study evaluation. The primary endpoint of the study was the proportion of plastic reconstruction and inpatient discharge. RESULTS Out of a total of 560 patients with rectal resections, 101 consecutive patients with ELAPE met the inclusion criteria and were included in the study evaluation. The primary direct defect closure was performed in 72 patients (71.3%). In 29 patients (28.7%), the defect was closed with primary unilateral or bilateral IGAP flaps in VY fashion. The patients' mean age was 59.4 years with a range of 25-85 years. In 84 patients, the indication of the operation was lower rectal cancer or anal cancer recurrence, and non-oncological resections were performed in 17 patients. Surgery was performed in a minimally invasive abdominal approach in combination with open perineal extralevatoric abdominoperineal resection (ELAPE) and immediate IGAP flap reconstruction. The rate of perineal early complications after plastic reconstruction was 19.0%, which needed local revision due to local infection. All these interventions were conducted under general anesthesia (Clavien-Dindo IIIb). The mean length of the hospital stay was 14.4 days after ELAPE, ranging from 3 to 53 days. CONCLUSIONS Since radical resection with a broad margin is the standard choice in primary, sphincter-infiltrating rectal cancer and recurrent anal cancer surgery in combination with ELAPE, the choice technique for pelvic floor reconstruction is under debate and there is no consensus. Using IGAP flaps is a reliable, technical, easy, and safe option, especially in wider defects on the pelvic floor with minimal donor site morbidity and an acceptable complication (no flap necrosis) rate. The data for hernia incidence in the long term are not known.
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Affiliation(s)
- J T Thiel
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, University of Tuebingen, 72076 Tuebingen, Germany
| | - H L Welskopf
- General, Visceral and Transplantation Surgery, Eberhard-Karl-Universität, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - C Yurttas
- General, Visceral and Transplantation Surgery, Eberhard-Karl-Universität, University Hospital Tübingen, 72076 Tuebingen, Germany
| | - F Farzaliyev
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, University of Tuebingen, 72076 Tuebingen, Germany
| | - A Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, University of Tuebingen, 72076 Tuebingen, Germany
| | - R Bachmann
- General, Visceral and Transplantation Surgery, Eberhard-Karl-Universität, University Hospital Tübingen, 72076 Tuebingen, Germany
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14
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Yuge K, Miwa K, Fujita F, Murotani K, Shigaki T, Yoshida N, Yoshida T, Koushi K, Fujiyoshi K, Nagasu S, Akagi Y. Comparison of long-term quality of life based on surgical procedure in patients with rectal cancer. Front Oncol 2023; 13:1197131. [PMID: 37274255 PMCID: PMC10235785 DOI: 10.3389/fonc.2023.1197131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction Reports on the long-term quality of life (QOL) over 3 years after surgery in patients who have undergone surgery for rectal cancer are limited. Therefore, we aimed to evaluate the long-term QOL of patients who underwent high anterior resection (HAR), low anterior resection (LAR), internal sphincter resection (ISR), or abdominoperineal resection (APR) for rectal cancer. Methods A questionnaire regarding QOL was sent to 360 patients with rectal cancer who underwent curative resection by HAR, LAR, ISR, or APR between January 2005 and December 2015. QOL was assessed using the short-form 36 (SF-36) and modified fecal incontinence QOL (mFIQL) questionnaire. QOL between surgical procedures was analyzed using a multivariate model adjusted for age, sex, and postoperative time. Results A total of 144 patients responded with a median follow-up period of 94 months (range 38-233 months). According to surgical procedure, HAR was performed in 26 patients, LAR in 80 patients, ISR in 32 patients, and APR in 6 patients. Patients who underwent HAR had significantly better mFIQL scores than those who underwent LAR and ISR (p=0.013 and p=0004, respectively) and significantly better role/social component summary scores on the SF-36 subscales (p=0.007). No difference was observed in the mFIQL scores between patients who underwent ISR and those who underwent APR (p=0.8423). In addition, postoperative anastomotic leakage sutures did not influence the mFIQL and SF-36 scores after surgery. Conclusion The QOL of patients who underwent anus-preserving surgery was best in the HAR group, with the QOL of other groups similar to the APR group. These results suggest that anus- preserving surgery is acceptable from a QOL standpoint. However, a colostomy may be a more satisfactory procedure in some patients.
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Affiliation(s)
- Kotaro Yuge
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Keisuke Miwa
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital, Kurume, Fukuoka, Japan
| | - Fumihiko Fujita
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Kenta Murotani
- Biostatistics Center, Kurume University, Kurume, Fukuoka, Japan
| | - Takahiro Shigaki
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Naohiro Yoshida
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Takefumi Yoshida
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Kenichi Koushi
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Kenji Fujiyoshi
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Sachiko Nagasu
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital, Kurume, Fukuoka, Japan
| | - Yoshito Akagi
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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15
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Mège D, de Chaisemartin C, Régis-Marigny L, Poizat F, Meillat H, Zemmour C, Moureau L, Lelong B. Supine bottom-up extralevator abdominoperineal excision for anorectal adenocarcinoma is not inferior to standard approach and may be thus safely performed. Surg Endosc 2023:10.1007/s00464-021-08982-1. [PMID: 36952048 DOI: 10.1007/s00464-021-08982-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/31/2021] [Indexed: 03/24/2023]
Abstract
BACKGROUND Extralevator abdominoperineal excision (APE) for rectal carcinoma has been described in order to improve pathological and oncological results compared to standard APE. To obtain the same oncological advantages as extralevator APE, we have previously described a new procedure starting by a perineal approach: the supine bottom-up APE. Our objective is to compare oncological and surgical outcomes between the supine bottom-up APE and the standard APE. METHODS All patients with low rectal adenocarcinoma requiring APE were retrospectively included and divided into 2 groups: supine bottom-up APE (Group A) and standard APE (Group B). RESULTS From 2008 to 2016, 61 patients were divided into Groups A (n = 30) and B (n = 31). Postoperative outcomes and median length of stay were similar between groups. Patients from Group A had a significantly longer distal margin (30 [8-120] vs. 20 [1.5-60] mm, p = 0.04) and higher number of harvested lymph nodes (14.5 [0-33] vs. 11 [5-25], p = 0.03) than those from Group B. Circumferential resection margin involvement was similar between groups (28 vs. 22%, p = 0.6), whereas tumors from Group A were significantly larger and more frequently classified as T4 than those from Group B. Operative time was significantly shorter in Group A (437.5 [285-655] minutes) than in Group B (537.5 [361-721] minutes, p = 0.0009). At the end of follow-up, local recurrence occurred in 7 and 16% of patients from Groups A and B (p = 0.68). Three-year overall and disease-free survival rates were similar between groups (87 vs. 90%, p = 0.62 and 61 vs. 63%, p = 0.88, respectively). CONCLUSION Our findings suggest that supine bottom-up APE doesn't impair surgical outcomes, pathological results, overall and disease-free survivals in comparison with standard APE. This new procedure may be thus safely performed and decrease the operative time. Further randomized multicentric studies are required to confirm these results.
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Affiliation(s)
- Diane Mège
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Cécile de Chaisemartin
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France.
| | - Laure Régis-Marigny
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Flora Poizat
- Department of Biopathology, Institut Paoli-Calmettes, Marseille, France
| | - Hélène Meillat
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Innovation, Biostatistics and Methodology Unit, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | - Laurence Moureau
- Radiation Oncology Department, Institut Paoli Calmettes, Marseille, France
| | - Bernard Lelong
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
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Bhattacharya P, Patel I, Fazili N, Hajibandeh S, Hajibandeh S. Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer: Importance of appropriate patient selection. World J Gastrointest Surg 2022; 14:1397-1410. [PMID: 36632123 PMCID: PMC9827567 DOI: 10.4240/wjgs.v14.i12.1397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/06/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Achieving a clear resection margins for low rectal cancer is technically challenging. Transanal approach to total mesorectal excision (TME) was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers. However, previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult.
AIM To investigate the outcomes of transanal TME (TaTME) and laparoscopic TME (LaTME) in patients with low rectal cancer.
METHODS A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. Intraoperative and postoperative complications, anastomotic leak, R0 resection, completeness of mesorectal excision, circumferential resection margin (CRM), distal resection margin (DRM), harvested lymph nodes, and operation time were the investigated outcome measures.
RESULTS We included twelve comparative studies enrolling 969 patients comparing TaTME (n = 969) and LaTME (n = 476) in patients with low rectal tumours. TaTME was associated with significantly lower risk of postoperative complications (OR: 0.74, P = 0.04), anastomotic leak (OR: 0.59, P = 0.02), and conversion to an open procedure (OR: 0.29, P = 0.002) in comparison with LaTME. Moreover, the rate of R0 resection was significantly higher in the TaTME group (OR: 1.96, P = 0.03). Nevertheless, TaTME and LaTME were comparable in terms of rate of intraoperative complications (OR: 1.87; P = 0.23), completeness of mesoractal excision (OR: 1.57, P = 0.15), harvested lymph nodes (MD: -0.05, P = 0.96), DRM (MD: -0.94; P = 0.17), CRM (MD: 1.08, P = 0.17), positive CRM (OR: 0.64, P = 0.11) and procedure time (MD: -6.99 min, P = 0.45).
CONCLUSION Our findings indicated that for low rectal tumours, TaTME is associated with better clinical and short term oncological outcomes compared to LaTME. More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.
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Affiliation(s)
- Pratik Bhattacharya
- Department of Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B71 4HJ, United Kingdom
| | - Ishaan Patel
- Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Noureen Fazili
- Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Shahab Hajibandeh
- Department of Surgery, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Shahin Hajibandeh
- Department of Surgery, Royal Stoke University Hospital, Stoke-on-Trent ST4 6QG, United Kingdom
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Zheng K, Hu Q, Yu G, Zhou L, Yao Y, Zhou Y, Wang H, Hao L, Yu E, Lou Z, Zhang Y, Qiu H, Meng R, Zhang W. Trends of sphincter-preserving surgeries for low lying rectal cancer: A 20-year experience in China. Front Oncol 2022; 12:996866. [PMID: 36568186 PMCID: PMC9773833 DOI: 10.3389/fonc.2022.996866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Background Over the last 2 decades, patients with low rectal cancer have had better outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trends in sphincter-preserving surgeries for low rectal cancer over 20 years in a top tertiary hospital in China. Methods Between 1999 and 2021, a cohort of patients with primary malignant rectal tumor ≤5cm from the anal verge and who received elective surgeries at Changhai Hospital, Shanghai, China, was identified. Data were extracted from electronic medical records. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). Adjusted Cox proportional hazards regression model was used to assess overall survival. Results Among a total of 4,172 patients during the study period, 3,111 (74.6%) underwent a sphincter-preserving surgery and 1,061 (25.4%) received APR. Sphincter-preserving surgery increased 3.6% per year (95%CI, 2.3-4.9). Low anterior resection was the most performed procedure (86.3%) and maintained a steady trend, while intersphincteric resection increased 49.4% annually (95%CI, 19.5-86.7) after initiation. Laparoscopic techniques increased 15.1% per year (95%CI, 8.4-43.4) after initiation. Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-≤3cm and 3-≤4cm from the anal verge (AAPC 7.1, 4.5-9.8; 4.7, 3.1-6.3; 2.7, 1.7-3.6, respectively). Furthermore, patients with sphincter-preserving surgery had a better overall survival than abdominoperineal resection (APR) patients (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01). Conclusions Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.
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Affiliation(s)
- Kuo Zheng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Qingqing Hu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Guanyu Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Leqi Zhou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Yuting Yao
- Department of Professional Education, Johnson & Johnson Medical (Shanghai) LTD, Shanghai, China
| | - Yuan Zhou
- Department of Professional Education, Johnson & Johnson Medical (Shanghai) LTD, Shanghai, China
| | - Hao Wang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Liqiang Hao
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Enda Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Zheng Lou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Yongjing Zhang
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Hong Qiu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Ronggui Meng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China,*Correspondence: Wei Zhang,
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Nagano H, Kajitani R, Ohno R, Munechika T, Matsumoto Y, Takahashi H, Aisu N, Kojima D, Yoshimatsu G, Hasegawa S, Kobayashi H, Sugihara K. Comparison of oncological outcomes between low anterior resection and abdominoperineal resection for rectal cancer: A retrospective cohort study using a multicenter database in Japan. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2467-2474. [PMID: 35752499 DOI: 10.1016/j.ejso.2022.06.002] [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: 02/22/2022] [Revised: 04/16/2022] [Accepted: 06/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND It remains controversial whether the abdominoperineal resection (APR) procedure itself has a negative impact on prognosis compared with sphincter-saving surgery (SSS). The purpose of this study was to investigate whether the operation type affects the prognostic outcome in rectal cancer using a multicenter database in Japan. METHODS The study involved 2533 patients who underwent APR or SSS and were registered in the Japanese Society for Cancer of the Colon and Rectum database, which includes data from 74 centers, between 2003 and 2007. The primary endpoints were overall survival (OS) and relapse-free survival (RFS). The secondary endpoints were local recurrence rate (LRR) and pathological radial margin (pRM) status. RESULTS Multivariate analysis identified pathological tumor depth, lymph node status, and pRM status to be associated with oncological outcomes (OS, RFS, LRR). Although the oncological outcomes were worse after APR than after SSS in univariate analysis, there was no significant difference in OS (hazard ratio 1.08; 95% confidence interval [CI] 0.85-1.37) or RFS (hazard ratio 1.06; 95% CI 0.87-1.30) between APR and SSS. There was also no significant difference in LRR (odds ratio 1.11, 95% CI 0.70-1.77). Multivariate analysis showed that operation type was associated with positive pRM (odds ratio 3.13, 95% CI 0.18-0.56). CONCLUSIONS There was no significant difference in oncological outcomes between APR and SSS for rectal cancer. The risk of positive pRM was higher for APR and performing radial margin-negative surgery is an important factor in improving the oncological outcomes of APR.
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Affiliation(s)
- Hideki Nagano
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Ryuji Kajitani
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Ryo Ohno
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Taro Munechika
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hiroyuki Takahashi
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Daibo Kojima
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago Takatsu-ku, Kawasaki, Kanagawa, 213-8504, Japan
| | - Kenichi Sugihara
- Tokyo Medical and Dental University, 1-5-45 Yushima Bunkyo-ku, Tokyo, 113-8510, Japan
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Song M, Wang H, Wang L, Li S, Zhang Y, Geng J, Zhu X, Li Y, Cai Y, Wang W. Dentate line invasion as a predictive factor of poor distant relapse-free survival in locally advanced lower rectal cancer with anal sphincter involvement. BMC Cancer 2022; 22:1196. [PMCID: PMC9675199 DOI: 10.1186/s12885-022-10299-8] [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: 05/31/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022] Open
Abstract
Background While an important surgical landmark of the dentate line has been established for locally advanced lower rectal cancer (LALRC), the prognostic significance of dentate line invasion (DLI) has not been well defined. This study aimed to explore the impact of DLI on prognosis in LALRC patients with anal sphincter involvement after neoadjuvant chemoradiotherapy followed by surgery. Methods We analyzed 210 LALRC patients and classified them into DLI group (n = 45) or non-DLI group (n = 165). The exact role of DLI in survival and failure patterns was assessed before and after propensity-score matching(PSM). Finally, 50 patients were matched. Results Before matching, patients in the DLI group had poorer 5-year distant relapse-free survival (DRFS) (P < 0.001), disease-free survival (DFS) (P < 0.001), and overall survival (OS) (P = 0.022) than those in the non-DLI group, with the exception of local recurrence-free survival (LRFS) (P = 0.114). After PSM, the 5-year DRFS, DFS, OS, and LRFS were 51.7% vs. 79.8%(P = 0.026), 51.7% vs. 79.8%(P = 0.029), 71.6% vs. 85.4%(P = 0.126), and 85.7% vs. 92.0%(P = 0.253), respectively, between the two groups. DLI was also an independent prognostic factor for poor DRFS with (Hazard ratio [HR] 3.843, P = 0.020) or without matching (HR 2.567, P = 0.001). The DLI group exhibited a higher rate of distant metastasis before (44.4% vs. 19.4%, P < 0.001) and after matching (48.0% vs. 20.0%, P = 0.037) and similar rates of locoregional recurrence before (13.3% vs.7.9%, P = 0.729) and after matching (16.0% vs.12.0%, P = 1.000). Conclusions DLI may portend worse DRFS and distant metastasis in LALRC patients with anal sphincter involvement, and this may be an important variable to guide clinicians. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10299-8.
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Affiliation(s)
- Maxiaowei Song
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Hongzhi Wang
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Lin Wang
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department 3 of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Shuai Li
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Yangzi Zhang
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Jianhao Geng
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Xianggao Zhu
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Yongheng Li
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Yong Cai
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
| | - Weihu Wang
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142 People’s Republic of China
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20
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May V, Bethune R. Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study. Colorectal Dis 2022; 24:1248. [PMID: 35791730 DOI: 10.1111/codi.16236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/11/2022] [Indexed: 02/08/2023]
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21
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Outcomes and Cost Analysis of Robotic Versus Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Case-Matched Study. Dis Colon Rectum 2022; 65:1279-1286. [PMID: 35195554 DOI: 10.1097/dcr.0000000000002394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although laparoscopy for abdominoperineal resection has been well defined, the literature lacks comparative studies on robotic abdominoperineal resection. Because robotic abdominoperineal resections typically do not require splenic mobilization or an anastomosis for reconstruction, the mean console time is expected to be shorter than low anterior resection. We hypothesized that robotic and laparoscopic abdominoperineal resection would provide similar oncologic and financial outcomes. OBJECTIVE The study aimed to compare the perioperative, oncologic, and economic outcomes of the robotic and laparoscopic abdominoperineal resection. DESIGN This was a retrospective, case-matched patient cohort. SETTINGS This study was conducted at a tertiary referral center. PATIENTS This study included all patients who underwent either laparoscopic or robotic abdominoperineal resections between January 2008 and April 2017; they were case-matched in a 1:1 ratio based on age ±5 years, BMI ±3 kg/m 2 , and sex criteria. MAIN OUTCOME MEASURES Perioperative, oncologic, and economic (including survival) outcomes were compared. Because of institutional policy, actual cost values are presented as the lowest direct cost value as "100%," and other values are presented as proportional to the index value. RESULTS We examined 68 patients (34 in each group). Both groups had similar preoperative characteristics, including preoperative chemoradiation rates. Operative time (319 vs 309 min), length of stay (7.2 vs 7.4 d), postoperative complications (38.2% vs 41.2%), conversion to open (5 vs 4), complete mesorectal excision (76.4% vs 79.4%), radial margin involvement (2.9% vs 8.9%), and direct hospital cost parameters (mean difference 26%, median difference 43%) were comparable between robotic and laparoscopic abdominoperineal resection groups, respectively (all p > 0.05). Local recurrence, disease-free survival, and overall survival rates (85.3% vs 76.5%) were also similar after 22 months of follow-up between the groups. LIMITATIONS The main limitations of this study are its retrospective nature and the variety in concomitant procedures. CONCLUSIONS Robotic abdominoperineal resections provided in carefully matched patients with rectal cancer showed similar perioperative and short-term oncologic outcomes compared to laparoscopic abdominoperineal resections. Our study was not powered to detect a significant increase in cost with robotic abdominoperineal resections. See Video Abstract at http://links.lww.com/DCR/B920 . RESULTADOS Y ANLISIS DE COSTO DE LA RESECCIN ABDOMINOPERINEAL LAPAROSCPICA VS LA ROBTICA EN CASOS DE CNCER DE RECTO ESTUDIO DE CASOS EMPAREJADOS ANTECEDENTES:Si bien la resección abdominoperineal laparoscópica está bien definida, la literatura carece de estudios comparativos sobre la resección abdominoperineal robótica. Dado que las resecciones abdominoperineales robóticas generalmente no requieren movilización esplénica o una anastomosis en casos de reconstrucción, se supone que el tiempo medio en la consola sea más corto que durante una resección anterior baja. Hipotéticamente las resecciones abdominoperineales robóticas y laparoscópicas nos proporcionarían resultados oncológicos y económicos similares.OBJETIVO:Comparar los resultados perioperatorios, oncológicos y económicos de la resección abdominoperineal robótica y laparoscópica.DISEÑO:Esta fue una cohorte de pacientes retrospectiva, emparejada por casos.AJUSTE:Estudio realizado en un centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a resecciones abdominoperineales LAParoscópicas o ROBóticas entre Enero de 2008 y Abril de 2017 fueron identificados y emparejados según la edad ±5, el IMC ±3 y los criterios de sexo en una proporción de 1:1.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados perioperatorios, oncológicos y económicos (incluida la sobrevida). Debido a la política institucional, los valores de costos reales se presentan como el valor de costo directo más bajo al 100% y los otros valores se presentan como proporcionales al valor índice.RESULTADOS:Se analizaron 68 pacientes (LAP-34 y ROB-34). Ambos grupos tenían características preoperatorias similares, incluidas las tasas de radio-quimioterapia pre-operatoria. Los tiempos operatorios fueron de 319 y 309 minutos, la estadía hospitalaria de 7 días en los dos grupos, las complicaciones post-operatorias fueron de 38,2% LAP frente a 41,2% ROB, la tasa de conversion fué de 5 a 4, la excisión total del mesorrecto de 76,4% frente a 79,4%, la resección radial con afectación de los márgenes de 2,9% frente a 8,9% y los parámetros de costes hospitalarios directos (diferencia de medias 26%, diferencia de medianas 43%) fueron comparables entre los grupos, de resección abdominoperineal robótica y laparoscópica, respectivamente (todos p > 0,05). Las tasas de recurrencia local, sobrevida libre de enfermedad y sobrevida general (85,3% frente a 76,5%) también fueron similares después de 22 meses de seguimiento entre los grupos.LIMITACIONES:La naturaleza retrospectiva y la variedad de procedimientos concomitantes fueron las principales limitaciones de este estudio.CONCLUSIONES:Las resecciones abdominoperineales robóticas proporcionaron resultados oncológicos perioperatorios y a corto plazo similares en pacientes con cáncer de recto cuidadosamente emparejados en comparación con las resecciones abdominoperineales laparoscópicas. Nuestro estudio no fue diseñado para detectar un aumento significativo en el costo relacionado con la resección abdominoperineal robótica. Consulte Video Resumen en http://links.lww.com/DCR/B920 . (Traducción-Dr. Xavier Delgadillo ).
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22
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Sun S, Sun S, Zheng X, Yu J, Wang W, Gong Q, Zhao G, Li J, Zhang H. Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment. BMC Cancer 2022; 22:916. [PMID: 36002810 PMCID: PMC9404665 DOI: 10.1186/s12885-022-10019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Extralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes. Methods Medical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed. Results The mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%. Conclusions Laparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10019-2.
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Affiliation(s)
- Shaowei Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Shengbo Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Xiangyun Zheng
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jiangtao Yu
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Wenchang Wang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Qing Gong
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Guowei Zhao
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jing Li
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China.
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23
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Chatila WK, Kim JK, Walch H, Marco MR, Chen CT, Wu F, Omer DM, Khalil DN, Ganesh K, Qu X, Luthra A, Choi SH, Ho YJ, Kundra R, Groves KI, Chow OS, Cercek A, Weiser MR, Widmar M, Wei IH, Pappou EP, Nash GM, Paty PB, Shi Q, Vakiani E, Duygu Selcuklu S, Donoghue MTA, Solit DB, Berger MF, Shia J, Pelossof R, Romesser PB, Yaeger R, Smith JJ, Schultz N, Sanchez-Vega F, Garcia-Aguilar J. Genomic and transcriptomic determinants of response to neoadjuvant therapy in rectal cancer. Nat Med 2022; 28:1646-1655. [PMID: 35970919 PMCID: PMC9801308 DOI: 10.1038/s41591-022-01930-z] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/29/2022] [Indexed: 01/03/2023]
Abstract
The incidence of rectal cancer is increasing in patients younger than 50 years. Locally advanced rectal cancer is still treated with neoadjuvant radiation, chemotherapy and surgery, but recent evidence suggests that patients with a complete response can avoid surgery permanently. To define correlates of response to neoadjuvant therapy, we analyzed genomic and transcriptomic profiles of 738 untreated rectal cancers. APC mutations were less frequent in the lower than in the middle and upper rectum, which could explain the more aggressive behavior of distal tumors. No somatic alterations had significant associations with response to neoadjuvant therapy in a treatment-agnostic manner, but KRAS mutations were associated with faster relapse in patients treated with neoadjuvant chemoradiation followed by consolidative chemotherapy. Overexpression of IGF2 and L1CAM was associated with decreased response to neoadjuvant therapy. RNA-sequencing estimates of immune infiltration identified a subset of microsatellite-stable immune hot tumors with increased response and prolonged disease-free survival.
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Affiliation(s)
- Walid K Chatila
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Tri-Institutional Program in Computational Biology and Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jin K Kim
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Henry Walch
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael R Marco
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chin-Tung Chen
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Fan Wu
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dana M Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Danny N Khalil
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Parker Institute for Cancer Immunotherapy, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Karuna Ganesh
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xuan Qu
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anisha Luthra
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Seo-Hyun Choi
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yu-Jui Ho
- Cancer Biology and Genetics Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ritika Kundra
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katharine I Groves
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oliver S Chow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian, New York, NY, USA
| | - Andrea Cercek
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil P Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Efsevia Vakiani
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Duygu Selcuklu
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark T A Donoghue
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David B Solit
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael F Berger
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jinru Shia
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raphael Pelossof
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rona Yaeger
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nikolaus Schultz
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Francisco Sanchez-Vega
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Liu ZH, Zeng ZW, Jie HQ, Huang L, Luo SL, Liang WF, Zhang XW, Kang L. Transanal total mesorectal excision combined with intersphincteric resection has similar long-term oncological outcomes to laparoscopic abdominoperineal resection in low rectal cancer: a propensity score-matched cohort study. Gastroenterol Rep (Oxf) 2022; 10:goac026. [PMID: 35711716 PMCID: PMC9195225 DOI: 10.1093/gastro/goac026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/29/2022] [Accepted: 05/07/2022] [Indexed: 12/03/2022] Open
Abstract
Background Transanal total mesorectal excision (taTME) or intersphincteric resection (ISR) has recently proven to be a valid and safe surgical procedure for low rectal cancer. However, studies focusing on the combination of these two technologies are limited. This study aimed to evaluate perioperative results, long-term oncologic outcomes, and anorectal functions of patients with low rectal cancer undergoing taTME combined with ISR, by comparing with those of patients undergoing laparoscopic abdominoperineal resection (laAPR). Methods After 1:1 propensity score matching, 200 patients with low rectal cancer who underwent laAPR (n = 100) or taTME combined with ISR (n = 100) between September 2013 and November 2019 were included. Patient demographics, clinicopathological characteristics, oncological outcomes, and anal functional results were analysed. Results Patients in the taTME-combined-with-ISR group had less intraoperative blood loss (79.6 ± 72.6 vs 107.3 ± 65.1 mL, P = 0.005) and a lower rate of post-operative complications (22.0% vs 44.0%, P < 0.001) than those in the laAPR group. The overall local recurrence rates were 7.0% in both groups within 3 years after surgery. The 3-year disease-free survival rates were 86.3% in the taTME-combined-with-ISR group and 75.1% in the laAPR group (P = 0.056), while the 3-year overall survival rates were 96.7% and 94.2%, respectively (P = 0.319). There were 39 patients (45.3%) in the taTME-combined-with-ISR group who developed major low anterior resection syndrome, whereas 61 patients (70.9%) had good post-operative anal function (Wexner incontinence score ≤ 10). Conclusion We found similar long-term oncological outcomes for patients with low rectal cancer undergoing laAPR and those undergoing taTME combined with ISR. Patients receiving taTME combined with ISR had acceptable post-operative anorectal function.
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Affiliation(s)
- Zhi-Hang Liu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Zi-Wei Zeng
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Hai-Qing Jie
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Liang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Shuang-Ling Luo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wen-Feng Liang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xing-Wei Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
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Rokan Z, Simillis C, Kontovounisios C, Moran B, Tekkis P, Brown G. Locally Recurrent Rectal Cancer According to a Standardized MRI Classification System: A Systematic Review of the Literature. J Clin Med 2022; 11:jcm11123511. [PMID: 35743581 PMCID: PMC9224654 DOI: 10.3390/jcm11123511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 12/15/2022] Open
Abstract
(1) Background: The classification of locally recurrent rectal cancer (LRRC) is not currently standardized. The aim of this review was to evaluate pelvic LRRC according to the Beyond TME (BTME) classification system and to consider commonly associated primary tumour characteristics. (2) Methods: A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE, and CENTRAL databases. The primary outcome was to assess the location and frequency of previously classified pelvic LRRC and translate this information into the BTME system. Secondary outcomes were assessing primary tumour characteristics. (3) Results: A total of 58 eligible studies classified 4558 sites of LRRC, most commonly found in the central compartment (18%), following anterior resection (44%), in patients with an 'advanced' primary tumour (63%) and following neoadjuvant radiotherapy (29%). Most patients also classified had a low rectal primary tumour. The lymph node status of the primary tumour leading to LRRC was comparable, with 52% node positive versus 48% node negative tumours. (4) Conclusions: This review evaluates the largest number of LRRCs to date using a single classification system. It has also highlighted the need for standardized reporting in order to optimise perioperative treatment planning.
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Affiliation(s)
- Zena Rokan
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Correspondence: (Z.R.); (C.K.)
| | - Constantinos Simillis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge CB2 0QQ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Chelsea & Westminster Hospital, London SW10 9NH, UK
- Correspondence: (Z.R.); (C.K.)
| | - Brendan Moran
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Basingstoke & North Hampshire Hospital, Basingstoke RG24 9NA, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
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Necessity of external iliac lymph nodes and inguinal nodes radiation in rectal cancer with anal canal involvement. BMC Cancer 2022; 22:657. [PMID: 35701738 PMCID: PMC9199347 DOI: 10.1186/s12885-022-09724-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022] Open
Abstract
Background and purpose We aimed to explore the necessity of the external iliac lymph nodes (EIN) along with inguinal nodes (IN) region in clinical target volume (CTV) for rectal carcinomas covering the anal canal region. Materials and methods This research premise enrolled 399 patients who had primary low rectal cancer detected below the peritoneal reflection via magnetic resonance imaging (MRI) and were treated with neoadjuvant radiotherapy (NRT), without elective EIN along with IN irradiation. We stratified the patients into two groups based on whether the lower edge of the rectal tumor extended to the anal canal (P group, n = 109) or not (Rb group, n = 290). Comparison of overall survival (OS), locoregional recurrence-free survival (LRFS), disease-free survival (DFS), as well as distant metastasis-free survival (DMFS) were performed via inverse probability of treatment weighting (IPTW) along with multivariable analyses. We compared the EIN and IN failure rates between the two groups via the Fisher and Gray’s test. Results P group showed a similar adjusted proportion along with five-year cumulative rate of EIN failure compared with the Rb group. The adjusted proportion and five-year cumulative rate of IN failure in the P group was higher in comparison to the Rb group. There were no remarkable differences in the adjusted five-year OS, DFS, DMFS or LRFS between the two groups. Anal canal involvement (ACI) exhibited no effect on OS, LRFS, DFS, or DMFS. Conclusions During NRT for rectal cancer with ACI, it may be possible to exclude the EIN and IN from the CTV.
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Kim JC, Park SH, Kim J, Kim CW, Park IJ, Yoon YS, Lee JL, Kim JH, Hong YS, Kim TW. Involvement of tissue changes induced by neoadjuvant treatment in total mesorectal excision (TME): novel suggestions for determining TME quality. Int J Colorectal Dis 2022; 37:1289-1300. [PMID: 35513539 DOI: 10.1007/s00384-022-04165-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few studies to date have investigated morphological changes after neoadjuvant treatment (NAT) and their implications in total mesorectal excision (TME). This study was primarily designed to evaluate whether tissue changes associated with NAT affected the quality of TME and additionally to suggest a more objective method evaluating TME quality. METHODS This study enrolled 1322 consecutive patients who underwent curative robot-assisted surgery for rectal cancer. Patients who did and did not receive NAT were subjected to propensity-score matching, yielding 402 patients in each group. RESULTS NAT independently reduced complete achievement of TME [odds ratio (OR) = 2.056, p = 0.017]. Intraoperative evaluation identified seven tissue changes significantly associated with NAT, including tumor perforation, mucin pool, necrosis, fibrosis, fat degeneration, and rectal or perirectal edema NAT (p < 0.001-0.05). Tumor perforation (OR = 5.299, p = 0.001) and mucin pool (OR = 14.053, p = 0.002) were independently associated with inappropriate (near-complete + incomplete) TME. Complete TME resulted in significantly reduced local recurrence (4.3% vs 15.3%, p = 0.003) and increased 5-year DFS rate (80.6% vs 67.6%, p = 0.047) compared with inappropriate one. By contrast, two tiers of complete and near-complete TMEs vs incomplete TME did not. Notably, among patients with complete TME, those who received NAT had a lower 5-year DFS than those who did not (77.8% vs 83.3%, p = 0.048). CONCLUSIONS NAT-associated tissue changes, somewhat interrupting complete TME, may provide unsolved clue to the relative inability of NAT to improve overall survival. The conventional three-tier grading of TME seems to be simplified into two tiers as complete and inappropriate.
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Affiliation(s)
- Jin Cheon Kim
- Department of Surgery, 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
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sik Yoon
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Lyul Lee
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sang Hong
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Tae Won Kim
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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Li L, Wang T, Hu D, Wu D, Bi L, Luo Y, Guo Y, Yang X. Pathologic outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of 26 studies. Int J Colorectal Dis 2022; 37:1063-1071. [PMID: 35411470 DOI: 10.1007/s00384-022-04147-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal total mesorectal excision (TaTME) has the potential advantages for patients with low rectal cancer. The objective of this meta-analysis was to identify the pathologic outcomes between the TaTME and laparoscopic total mesorectal excision (LaTME) in rectal cancer. METHODS The literature searches were conducted in PubMed, Cochrane Library, and EMBASE with English language restriction. The primary endpoint was circumferential margin (CRM), and the secondary endpoints were distal resection margin (DRM), mesorectal excision quality, and harvested lymph nodes. RESULTS Our research identified 1090 articles, and 26 studies met the inclusion criteria for the meta-analysis. The positive CRM was lower in the TaTME than the LaTME (OR = 0.72; 95% CI = 0.53, 0.98; P = 0.04). There was no significant difference in the positive CRM between the TaTME and LaTME published after 2016 (OR = 0.80; 95% CI = 0.57, 1.12; P = 0.19), prospective study (OR = 2.70; 95% CI = 0.51, 14.24; P = 0.24), respective study (OR = 0.76; 95% CI = 0.55, 1.04; P = 0.09), BMI > 26 (OR = 1.00; 95% CI = 0.63, 1.58; P = 0.98), or sample size > 100 (OR = 0.84; 95% CI = 0.57, 1.23; P = 0.38). In addition, there was no significant difference observed between the TaTME and LaTME in terms of DRM, mesorectum incompleteness, and harvested lymph nodes. CONCLUSIONS The TaTME is associated with lower positive CRM compared to the LaTME and similar pathologic outcomes including DRM, harvested lymph node, and mesorectal excision quality.
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Affiliation(s)
- Laiyuan Li
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Wang
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dongping Hu
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dewang Wu
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Liang Bi
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yang Luo
- Department of Neurology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yinyin Guo
- Department of Pharmacy, Lanzhou University Second Hospital, Lanzhou, China
| | - Xiongfei Yang
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China.
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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] [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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Cheah WH. Pictorial essay on MRI local staging of rectal carcinoma: An easy approach. Asia Pac J Clin Oncol 2022; 19:e80-e88. [PMID: 35437926 DOI: 10.1111/ajco.13782] [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: 02/03/2021] [Revised: 01/20/2022] [Accepted: 03/21/2022] [Indexed: 11/27/2022]
Abstract
Rectal cancer is common and accounts for more than one-third of colorectal tumors. It is associated with significant morbidity and mortality. Previously computed tomography scan is the key imaging modality in preoperative assessment to detect local invasion and distant metastasis. However, the advent of magnetic resonance imaging (MRI) has aided in local staging and prognosticates the outcome of rectal tumor. Here, the author briefly explains why rectal MRI has a comprehensive role and provides a simple and easy way in reporting an MRI rectal carcinoma, even for a non-radiologist.
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Affiliation(s)
- Wai-Hun Cheah
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Malaysia
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31
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Caycedo-Marulanda A, Verschoor CP, Brown CP, Karimuddin A, Raval M, Phang T, Vikis E, Melich G, Patel SV. Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study. Colorectal Dis 2022; 24:380-387. [PMID: 34957663 DOI: 10.1111/codi.16033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 02/08/2023]
Abstract
AIM The main objective of this study was to compare the oncological outcomes of patients undergoing abdominoperineal resection (APR) versus low anterior resection (LAR) through a transanal total mesorectal excision (taTME) approach. METHOD A total of 360 adult patients with a diagnosis of rectal cancer were enrolled at participating centres from the Canadian taTME Expert Collaboration. Forty-three patients received taTME-APR and received 317 taTME-LAR. Demographic, operative, pathological and follow-up data were collected and merged into a single database. Results are presented as hazard ratio (HR) and 95% confidence interval. All analyses were performed in the R environment (v.3.6). RESULTS The proportion of patients with a positive circumferential radial margin status was higher in the taTME-APR group than the taTME-LAR group (21% vs. 9%, p = 0.001). Complete TME was achieved in 91% of those undergoing APR compared with 96% of those undergoing LAR (p = 0.25). APR was associated with a greater rate of local recurrence relative to LAR, although it was not significant [crude HR = 3.53 (95% CI 0.92-13.53)]. Circumferential margin positivity was significantly associated with a higher rate of systemic recurrence [crude HR = 3.59 (95% CI 1.38-9.3)]. CONCLUSION Our results demonstrate inferior outcomes in those undergoing taTME-APR compared with taTME-LAR. The use of this technique for this particular indication needs to be carefully considered.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Kingston General Hospital, Queen's University, Kingston, ON, Canada.,Health Sciences North Research Institute, Sudbury, ON, Canada
| | | | - Carl P Brown
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ahmer Karimuddin
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Manoj Raval
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Terry Phang
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Elena Vikis
- Royal Columbian Hospital/Eagle Ridge Hospital, University of British Columbia, Vancouver, BC, Canada
| | - George Melich
- Royal Columbian Hospital/Eagle Ridge Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sunil V Patel
- Kingston General Hospital, Queen's University, Kingston, ON, Canada
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Nougaret S, Rousset P, Gormly K, Lucidarme O, Brunelle S, Milot L, Salut C, Pilleul F, Arrivé L, Hordonneau C, Baudin G, Soyer P, Brun V, Laurent V, Savoye-Collet C, Petkovska I, Gerard JP, Rullier E, Cotte E, Rouanet P, Beets-Tan RGH, Frulio N, Hoeffel C. Structured and shared MRI staging lexicon and report of rectal cancer: A consensus proposal by the French Radiology Group (GRERCAR) and Surgical Group (GRECCAR) for rectal cancer. Diagn Interv Imaging 2022; 103:127-141. [PMID: 34794932 DOI: 10.1016/j.diii.2021.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE To develop French guidelines by experts to standardize data acquisition, image interpretation, and reporting in rectal cancer staging with magnetic resonance imaging (MRI). MATERIALS AND METHODS Evidence-based data and opinions of experts of GRERCAR (Groupe de REcherche en Radiologie sur le CAncer du Rectum [i.e., Rectal Cancer Imaging Research Group]) and GRECCAR (Groupe de REcherche en Chirurgie sur le CAncer du Rectum [i.e., Rectal Cancer Surgery Research Group]) were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of reporting template and protocol for data acquisition were collected; responses were analyzed and classified as "Recommended" versus "Not recommended" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts). RESULTS Consensus regarding patient preparation, MRI sequences, staging and reporting was attained using the RAND-UCLA Appropriateness Method. A consensus was reached for each reporting template item among the experts. Tailored MRI protocol and standardized report were proposed. CONCLUSION These consensus recommendations should be used as a guide for rectal cancer staging with MRI.
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Affiliation(s)
- Stephanie Nougaret
- Department of Radiology, Institut Régional du Cancer de Montpellier, Montpellier Cancer Research Institute, INSERM U1194, University of Montpellier, 34295, Montpellier, France.
| | - Pascal Rousset
- Department of Radiology, Lyon 1 Claude-Bernard University, 69495 Pierre-Benite, France
| | - Kirsten Gormly
- Dr Jones & Partners Medical Imaging, Kurralta Park, 5037, Australia; University of Adelaide, North Terrace, Adelaide, South Australia 5000, Australia
| | - Oliver Lucidarme
- Department of Radiology, Pitié-Salpêtrière Hospital, Sorbonne Université, 75013 Paris, France; LIB, INSERM, CNRS, UMR7371-U1146, 75013 Paris, France
| | - Serge Brunelle
- Department of Radiology, Institut Paoli-Calmettes, 13009 Marseille, France
| | - Laurent Milot
- Radiology Department, Hospices Civils de Lyon, Lyon Sud University Hospital, 69495 Pierre Bénite, France; Lyon 1 Claude Bernard University, 69100 Villeurbanne, France
| | - Cécile Salut
- Department of Radiology, CHU de Bordeaux, Université de Bordeaux, 33000 Bordeaux, France
| | - Franck Pilleul
- Department of Radiology, Centre Léon Bérard, Lyon, France Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, 69621, Lyon, France
| | - Lionel Arrivé
- Department of Radiology, Hopital St Antoine, Paris, France
| | - Constance Hordonneau
- Department of Radiology, CHU Estaing, Université Clermont-Auvergne, 63000 Clermont-Ferrand, France
| | - Guillaume Baudin
- Department of Radiology, Centre Antoine Lacassagne, 06100 Nice, France
| | - Philippe Soyer
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Vanessa Brun
- Department of Radiology, CHU Hôpital Pontchaillou, 35000 Rennes Cedex, France
| | - Valérie Laurent
- Department of Radiology, Brabois-Nancy University Hospital, Université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France
| | | | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jean Pierre Gerard
- Department of Radiotherapy, Centre Antoine Lacassagne, 06100 Nice, France
| | - Eric Rullier
- Department of Digestive Surgery, Hôpital Haut-Lévèque, Université de Bordeaux, 33600 Pessac, France
| | - Eddy Cotte
- Department of Digestive Surgery, Hospices Civils de Lyon, Lyon Sud University Hospital, 69310 Pierre Bénite, France; Lyon 1 Claude Bernard University, 69100 Villeurbanne, France
| | - Philippe Rouanet
- Department of surgery, Institut Régional du Cancer de Montpellier, Montpellier Cancer Research Institute, INSERM U1194, University of Montpellier, 34295, Montpellier, France
| | - Regina G H Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute, 1066 CX, Amsterdam, the Netherlands
| | - Nora Frulio
- Department of Radiology, CHU de Bordeaux, Université de Bordeaux, 33000 Bordeaux, France
| | - Christine Hoeffel
- Department of Radiology, Hôpital Robert Debré & CRESTIC, URCA, 51092 Reims, France
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Fernandes MC, Gollub MJ, Brown G. The importance of MRI for rectal cancer evaluation. Surg Oncol 2022; 43:101739. [PMID: 35339339 PMCID: PMC9464708 DOI: 10.1016/j.suronc.2022.101739] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 12/19/2022]
Abstract
Magnetic resonance imaging (MRI) has gained increasing importance in the management of rectal cancer over the last two decades. The role of MRI in patients with rectal cancer has expanded beyond the tumor-node-metastasis (TNM) system in both staging and restaging scenarios and has contributed to identifying "high" and "low" risk features that can be used to tailor and personalize patient treatment; for instance, selecting the patients for neoadjuvant chemoradiation (NCRT) before the total mesorectal excision (TME) surgery based on risk of recurrence. Among those features, the status of the circumferential resection margin (CRM), extramural vascular invasion (EMVI), and tumor deposits (TD) have stood out. Moreover, MRI also has played a role in surgical planning, especially when the tumor is located in the low rectum, when the relationship between tumor and the anal canal is important to choose the best surgical approach, and in cases of locally advanced or recurrent tumors invading adjacent pelvic organs that may require more complex surgeries such as pelvic exenteration. As approaches using organ preservation emerge, including transanal local excision and "watch-and-wait", MRI may help in the patient selection for those treatments, follow up, and detection of tumor regrowth. Additionally, potential MRI-based prognostic and predictive biomarkers, such as quantitative and semi-quantitative metrics derived from functional sequences like diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE), and radiomics, are under investigation. This review provides an overview of the current role of MRI in rectal cancer in staging and restaging and highlights the main areas under investigation and future perspectives.
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Loughrey MB, Webster F, Arends MJ, Brown I, Burgart LJ, Cunningham C, Flejou JF, Kakar S, Kirsch R, Kojima M, Lugli A, Rosty C, Sheahan K, West NP, Wilson RH, Nagtegaal ID. Dataset for Pathology Reporting of Colorectal Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR). Ann Surg 2022; 275:e549-e561. [PMID: 34238814 PMCID: PMC8820778 DOI: 10.1097/sla.0000000000005051] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study to describe a new international dataset for pathology reporting of colorectal cancer surgical specimens, produced under the auspices of the International Collaboration on Cancer Reporting (ICCR). BACKGROUND Quality of pathology reporting and mutual understanding between colorectal surgeon, pathologist and oncologist are vital to patient management. Some pathology parameters are prone to variable interpretation, resulting in differing positions adopted by existing national datasets. METHODS The ICCR, a global alliance of major pathology institutions with links to international cancer organizations, has developed and ratified a rigorous and efficient process for the development of evidence-based, structured datasets for pathology reporting of common cancers. Here we describe the production of a dataset for colorectal cancer resection specimens by a multidisciplinary panel of internationally recognized experts. RESULTS The agreed dataset comprises eighteen core (essential) and seven non-core (recommended) elements identified from a review of current evidence. Areas of contention are addressed, some highly relevant to surgical practice, with the aim of standardizing multidisciplinary discussion. The summation of all core elements is considered to be the minimum reporting standard for individual cases. Commentary is provided, explaining each element's clinical relevance, definitions to be applied where appropriate for the agreed list of value options and the rationale for considering the element as core or non-core. CONCLUSIONS This first internationally agreed dataset for colorectal cancer pathology reporting promotes standardization of pathology reporting and enhanced clinicopathological communication. Widespread adoption will facilitate international comparisons, multinational clinical trials and help to improve the management of colorectal cancer globally.
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Affiliation(s)
- Maurice B Loughrey
- Centre for Public Health, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, UK
- Department of Cellular Pathology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Fleur Webster
- International Collaboration on Cancer Reporting, Sydney, NSW, Australia
| | - Mark J Arends
- Division of Pathology, Institute of Genetics & Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Ian Brown
- Envoi Pathology, Kelvin Grove, QLD, Australia
| | - Lawrence J Burgart
- Department of Pathology, Virginia Piper Cancer Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Chris Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHSFT, Oxford, UK
| | - Jean-Francois Flejou
- Department of Pathology, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - Sanjay Kakar
- Department of Pathology, University of California San Francisco, San Francisco, CA
| | - Richard Kirsch
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Motohiro Kojima
- Division of Pathology, Research Center for Innovative Oncology, National Cancer Center, Chiba, Kashiwa, Japan
| | | | - Christophe Rosty
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Envoi Specialist Pathologists, Brisbane, QLD, Australia
- Department of Pathology, University of Melbourne, Melbourne, VIC, Australia
| | - Kieran Sheahan
- Department of Pathology, St Vincent's University Hospital & University College, Dublin, Ireland
| | - Nicholas P West
- Pathology and Data Analytics, Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Richard H Wilson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Short-Term Outcomes with Standardized Transperineal Minimally Invasive Abdominoperineal Excision for Rectal Cancer. J Gastrointest Surg 2022; 26:713-719. [PMID: 34608600 DOI: 10.1007/s11605-021-05140-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transperineal abdominoperineal excision (TpAPE) is an emerging approach for low rectal cancers but is technically challenging. Based on an anatomical study we conducted previously, we have standardized the TpAPE procedure. Here, we aimed to validate the feasibility of the standardized TpAPE by investigating the short-term outcomes. METHODS From January 2018 to November 2020, a total of 405 patients underwent laparoscopic or robotic rectal resection for rectal cancer in our institution. For the current study, we analyzed data for the 31 patients who underwent TpAPE. The abdominal phase was performed synchronously with the perineal phase using either a laparoscopic or robotic approach. Short-term outcomes included operative and pathological results. RESULTS Of the 31 cases, we identified anterior quadrant tumor invasion in 21. Most of the cases were advanced, with 6 staged as cT3 and 20 as T4. Of the 27 cases not involving distant metastasis, neoadjuvant therapy was performed in 19. No inadvertent rectal perforation or urethral injury was found intraoperatively. The median procedural duration to specimen removal was 250 min (interquartile range, 204-287), and the median intraoperative blood loss was 10 ml (interquartile range, 5-40). Regarding postoperative complications, perineal wound infection developed in 11 cases. A positive circumferential resection margin was found in 3, corresponding to the positive rate of 9.7%. These three cases were among the first 12 cases involving standardized TpAPE. CONCLUSIONS The current results indicate that TpAPE can be performed safely and might represent a useful option for low rectal cancer resection.
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Segev L, Schtrechman G, Kalady MF, Liska D, Gorgun IE, Valente MA, Nissan A, Steele SR. Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience. Dis Colon Rectum 2022; 65:361-372. [PMID: 34784318 DOI: 10.1097/dcr.0000000000002067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Randomized studies have validated laparoscopic proctectomy for the treatment of rectal cancer as noninferior to an open proctectomy, but most of those studies have included sphincter-preserving resections along with abdominoperineal resection. OBJECTIVE This study aimed to compare perioperative and long-term oncological outcomes between minimally invasive and open abdominoperineal resection. DESIGN This study is a retrospective analysis of a prospectively maintained database. SETTINGS The study was conducted in a single specialized colorectal surgery department. PATIENTS All patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2016 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the perioperative and long-term oncological outcomes. RESULTS We included 452 patients, 372 in the open group and 80 in the minimally invasive group, with a median follow-up time of 74 months. There were significant differences between the groups in terms of neoadjuvant radiation treatment (67.5% of the open versus 81.3% of the minimally invasive group, p = 0.01), operative time (mean of 200 minutes versus 287 minutes, p < 0.0001), and mean length of stay (9.5 days versus 6.6 days, p < 0.0001). Overall complication rates were similar between the groups (34.5% versus 27.5%, p = 0.177). There were no significant differences in the mean number of lymph nodes harvested (21.7 versus 22.2 nodes, p = 0.7), circumferential radial margins (1.48 cm versus 1.37 cm, p = 0.4), or in the rate of involved radial margins (10.8% versus 6.3%, p = 0.37). Five-year overall survival was 70% in the open group versus 80% in the minimally invasive group (p = 0.344), whereas the 5-year disease-free survival rate in the open group was 63.2% versus 77.6% in the minimally invasive group (p = 0.09). LIMITATIONS This study was limited because it describes a single referral institution experience. CONCLUSIONS Although both approaches have similar perioperative outcomes, the minimally invasive approach benefits the patients with a shorter length of stay and a lower risk for surgical wound infections. Both approaches yield similar oncological technical quality in terms of the lymph nodes harvested and margins status, and they have comparable long-term oncological outcomes. See Video Abstract at http://links.lww.com/DCR/B754.RESULTADOS A LARGO PLAZO DE LA RESECCIÓN ABDOMINOPERINEAL MÍNIMAMENTE INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: EXPERIENCIA DE UN SOLO CENTRO ESPECIALIZADOANTECEDENTES:Estudios aleatorizados han validado la proctectomía laparoscópica para el tratamiento del cáncer de recto igual a la proctectomía abierta, pero la mayoría de esos estudios han incluido resecciones con preservación del esfínter junto con resección abdominoperineal.OBJETIVO:Comparar los resultados oncológicos perioperatorios y a largo plazo entre la resección abdominoperineal abierta y mínimamente invasiva.DISEÑO:Análisis retrospectivo de una base de datos mantenida de forma prospectiva.ENTORNO CLINICO:Servicio único especializado en cirugía colorrectal.PACIENTES:Todos los pacientes que se sometieron a resección abdominoperineal por cáncer de recto primario entre 2000 y 2016.PRINCIPALES MEDIDAS DE VALORACION:Resultados oncológicos perioperatorios y a largo plazo.RESULTADOS:Se incluyeron 452 pacientes, 372 en el grupo abierto y 80 en el grupo mínimamente invasivo, con una mediana de seguimiento de 74 meses. Hubo diferencias significativas entre los grupos en términos de tratamiento con radiación neoadyuvante (67,5% del grupo abierto versus 81,3% del grupo mínimamente invasivo, p = 0,01), tiempo operatorio (media de 200 minutos versus 287 minutos, p < 0,0001) y la duración media de la estancia (9,5 días frente a 6,6 días, p < 0,0001). Las tasas generales de complicaciones fueron similares entre los grupos (34,5% versus 27,5%, p = 0,177). No hubo diferencias significativas en el número medio de ganglios linfáticos extraídos (21,7 versus 22,2 ganglios, p = 0,7), márgenes radiales circunferenciales (1,48 cm y 1,37 cm, p = 0,4), ni en la tasa de márgenes radiales afectados (10,8 cm). % versus 6,3%, p = 0,37). La supervivencia general a 5 años fue del 70% en el grupo abierto frente al 80% en el grupo mínimamente invasivo (p = 0,344), mientras que la tasa de supervivencia libre de enfermedad a 5 años en el grupo abierto fue del 63,2% frente al 77,6% en el grupo mínimamente invasivo (p = 0,09).LIMITACIONES:Experiencia en una institución de referencia única.CONCLUSIONES:Si bien ambos tienen resultados perioperatorios similares, el enfoque mínimamente invasivo, beneficia a los pacientes con estadía más corta y menor riesgo de infecciones de la herida quirúrgica. Ambos enfoques, producen una calidad técnica oncológica similar en términos de ganglios linfáticos extraídos y estado de los márgenes, y tienen resultados oncológicos comparables a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B754. (Traducción - Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Lior Segev
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gal Schtrechman
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - I Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Aviram Nissan
- Department of Surgical Oncology - Surgery C, Sheba Medical center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Oerskov KM, Bondeven P, Laurberg S, Hagemann-Madsen RH, Christensen HK, Lauridsen H, Pedersen BG. Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer. Front Surg 2021; 8:771107. [PMID: 34869567 PMCID: PMC8635027 DOI: 10.3389/fsurg.2021.771107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/04/2021] [Indexed: 01/11/2023] Open
Abstract
Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038). Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.
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Affiliation(s)
| | - Peter Bondeven
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Henrik Lauridsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Mendis S, To YH, Tie J. Biomarkers in Locally Advanced Rectal Cancer: A Review. Clin Colorectal Cancer 2021; 21:36-44. [PMID: 34961731 DOI: 10.1016/j.clcc.2021.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/03/2022]
Abstract
Locally advanced rectal cancers (LARC) are the subject of a rapidly evolving treatment paradigm. The critical timepoints where management decisions are required during the care of the LARC patient are: prior to the institution of any treatment, post neoadjuvant therapy and post-surgery. This article reviews the clinical, imaging, blood-based, tissue-based, and molecular biomarkers that can assist clinicians at these timepoints in the patient's management, in prognosticating for their LARC patients or in predicting responses to therapy in the multi-modality neoadjuvant treatment era.
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Affiliation(s)
- Shehara Mendis
- Walter and Eliza Hall Institute, 1G Royal Parade, Parkville VIC 3052, Australia; 2. Western Health, Melbourne, VIC, Australia.
| | - Yat Hang To
- Walter and Eliza Hall Institute, 1G Royal Parade, Parkville VIC 3052, Australia; Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jeanne Tie
- Walter and Eliza Hall Institute, 1G Royal Parade, Parkville VIC 3052, Australia; Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Ptok H, Meyer F, Gastinger I, Garlipp B. Multimodal Treatment of cT3 Rectal Cancer in a Prospective Multi-Center Observational Study: Can Neoadjuvant Chemoradiation Be Omitted in Patients with an MRI-Assessed, Negative Circumferential Resection Margin? Visc Med 2021; 37:410-417. [PMID: 34722724 DOI: 10.1159/000514800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Background/Aim Neoadjuvant chemoradiation (nCRT) in rectal cancer is associated with significant long-term morbidity. It is unclear whether nCRT in resectable mesorectal fascia circumferential resection margin (mrCRM)-negative rectal cancer treated by adequate total mesorectal excision (TME) is beneficial. The aim was to determine if nCRT can be omitted in patients with MRI-assessed cT3 rectal cancer and a negative mrCRM undergoing good-quality TME. Methods By means of a prospective nationwide registry (n = 43.147; prospective multi-center observational study), patients with cT3 rectal cancer <12 cm from the anal verge with a negative (>1 mm) MRI-assessed CRM undergoing radical resection from 2006 to 2008 were selected. Overall, 87 patients were available for the final analysis (TME-alone, n = 25; nCRT+TME, n = 62). Groups were balanced for age, sex, and ASA score, with a nonsignificant predominance of males in the nCRT+TME group. As main outcome measures, local and distant recurrence rates were compared between patients undergoing primary surgery (TME-alone) vs. neoadjuvant chemoradiation + surgery (nCRT+TME). Results In the TME-alone group, tumors were located closer to the anal verge (p = 0.018) and demonstrated a smaller minimal circumferential distance from the resection margin (p = 0.036). TME quality was comparable, as was median follow-up (48.9 vs. 44.9 months; p = 0.268). Local recurrences occurred at a similar rate in the TME-alone (n = 1; 5.3%) and nCRT+TME groups (n = 3; 5.5%) (p = 0.994) and were diagnosed at 10 months (TME-alone) and at 8, 13, and 18 months (nCRT+TME). Distant recurrences occurred in 28.9 and 17.4% of the cases, respectively (p = 0.626). The analysis was limited to cT3 cancers with a negative mrCRM. In addition, caution is required when appraising these results because of the limited number of evaluable subjects (especially in the TME-alone group), which adds some uncertainty to the statistical analysis. Conclusions In this cohort of patients with rectal cancer located <12 cm from the anal verge and a negative mrCRM undergoing adequate TME, omission of nCRT had no impact onto the local recurrence rate.
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Affiliation(s)
- Henry Ptok
- Department of General, Abdominal, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany.,Institute of Quality Assurance in Operative Medicine, University of Magdeburg, Magdeburg, Germany
| | - Frank Meyer
- Department of General, Abdominal, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany.,Institute of Quality Assurance in Operative Medicine, University of Magdeburg, Magdeburg, Germany
| | - Ingo Gastinger
- Institute of Quality Assurance in Operative Medicine, University of Magdeburg, Magdeburg, Germany
| | - Benjamin Garlipp
- Department of Surgery (Oranienburg), Regional Hospital (Oberhavel Kliniken) at Hennigsdorf, Hennigsdorf, Germany
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Sharabiany S, Strijk GJ, Blok RD, Ferrett CG, Stoker J, Cunningham C, van der Bilt JDW, van Geloven AAW, Bemelman WA, Hompes R, Musters GD, Tanis PJ. Quantifying displacement of urogenital organs after abdominoperineal resection for rectal cancer. Colorectal Dis 2021; 23:2923-2931. [PMID: 34427972 PMCID: PMC9291959 DOI: 10.1111/codi.15885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to quantify displacement of urogenital organs after abdominoperineal resection (APR), and to explore patient and treatment characteristics associated with displacement. METHOD Patients from 16 centres who underwent APR for primary or recurrent rectal cancer (2001-2018) with evaluable preoperative and 6-18 months postoperative radiological imaging were included in the study. Anatomical landmarks on sagittal images were related to a coordinate system based on reference lines between fixed bony structures and absolute displacements were calculated using the Pythagorean theorem. Rotation of landmarks was measured relative to a pubic-S5 reference line. RESULTS There were 248 patients included of which 171 were men and 77 women. The median displacement of the internal urethral orifice was 25 mm in men (maximum 65), and 17 mm in women (maximum 50). Rotation of the internal urethral orifice was in a caudal direction in 160/170 (94%) of men and 65/73 (89%) of women, with a median of 32 degrees (maximum 85) and 33 degrees (maximum 83), respectively. Displacements of the posterior bladder wall, distal end of prostatic urethra and cervix were significantly correlated with the internal urethral orifice. In linear regression analysis, biological mesh reconstruction of the pelvic floor and visceral interposition were significantly associated with increased displacement of the internal urethral orifice, and female gender and any filling of the presacral space with decreased displacement. CONCLUSIONS Substantial absolute displacement and rotation of urogenital organs after APR for rectal cancer were observed, but with high variability among both men and women, and being significantly associated with reconstructive interventions.
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Affiliation(s)
- Sarah Sharabiany
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gaby J. Strijk
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Robin D. Blok
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Colin G. Ferrett
- Department of RadiologyOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Jaap Stoker
- Department of RadiologyAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Christopher Cunningham
- Department of Colorectal SurgeryChurchill HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
| | | | | | - Wilhelmus A. Bemelman
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Roel Hompes
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gijsbert D. Musters
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryAmsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
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Is elective inguinal or external iliac irradiation during neoadjuvant (chemo)radiotherapy necessary for locally advanced lower rectal cancer with anal sphincter invasion? Pract Radiat Oncol 2021; 12:125-134. [PMID: 34670136 DOI: 10.1016/j.prro.2021.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/19/2021] [Accepted: 10/08/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To investigate the impact of excluding irradiation of inguinal lymph nodes (ILNs) and external iliac lymph nodes (ELNs) during neoadjuvant (chemo)radiotherapy in a locally advanced lower rectal cancer (LALRC) with anal sphincter invasion. MATERIALS AND METHODS A total of 214 LALRC patients with anal sphincter invasion according to pre-treatment magnetic resonance imaging who underwent neoadjuvant (chemo)radiotherapy followed by surgery between September 2010 and May 2019 were enrolled. ILNs and ELNs were clinically negative pre-treatment and were excluded from irradiation. Failure rates and patterns of ILNs and ELNs and survival were analyzed. Nomograms for predicting ILN and ELN failure risk were also constructed. RESULTS The median follow-up was 53.3 months. The three-year failure rates were 3.7% for ILNs and 3.3% for ELNs. Only one patient developed isolated ILN failure, and no patient experienced isolated ELN failure. Multivariate analyses demonstrated that lower edge of tumors invaded or located below the dentate line (odds ratio [OR] 7.513, P = 0.013), high histological grade (OR 6.892, P = 0.017), and perineural invasion (OR 7.111, P = 0.023) were significantly related to ILN failure. Both perineural invasion (OR 8.923, P = 0.011) and high histological grade (OR 8.129, P = 0.011) showed a strong correlation with ELN failure. The concordance index of nomograms for predicting ILN and ELN failure risk were 0.842 and 0.880, respectively. The three-year local recurrence free survival, disease-free survival, and overall survival were 94.6% (95% confidence interval [CI], 91.3%‒97.9%), 77.7% (95% CI, 71.8%‒83.6%), and 91.9% (95% CI, 87.8%‒96.0%), respectively, for the whole cohort. CONCLUSIONS Excluding ILNs and ELNs from irradiation was associated with an acceptably low failure risk for LALRC invading the anal sphincter. These findings help to refine existing guidelines for clinical target volume delineation of ILNs and ELNs during neoadjuvant (chemo)radiotherapy in rectal cancer.
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Chin RI, Roy A, Pedersen KS, Huang Y, Hunt SR, Glasgow SC, Tan BR, Wise PE, Silviera ML, Smith RK, Suresh R, Badiyan SN, Shetty AS, Henke LE, Mutch MG, Kim H. Clinical Complete Response in Patients With Rectal Adenocarcinoma Treated With Short-Course Radiation Therapy and Nonoperative Management. Int J Radiat Oncol Biol Phys 2021; 112:715-725. [PMID: 34653579 DOI: 10.1016/j.ijrobp.2021.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/11/2021] [Accepted: 10/05/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE This study aimed to determine the clinical efficacy and safety of nonoperative management (NOM) for patients with rectal cancer with a clinical complete response (cCR) after short-course radiation therapy and consolidation chemotherapy. METHODS AND MATERIALS Patients with stage I-III rectal adenocarcinoma underwent short-course radiation therapy followed by consolidation chemotherapy between January 2018 and May 2019 (n = 90). Clinical response was assessed by digital rectal examination, pelvic magnetic resonance imaging, and endoscopy. Of the patients with an evaluable initial response, those with a cCR (n = 43) underwent NOM, and those with a non-cCR (n = 43) underwent surgery. The clinical endpoints included local regrowth-free survival, regional control, distant metastasis-free survival, disease-free survival, and overall survival. RESULTS Compared with patients with an initial cCR, patients with initial non-cCR had more advanced T and N stage (P = .05), larger primary tumors (P = .002), and more circumferential resection margin involvement on diagnostic magnetic resonance imaging (P < .001). With a median follow-up of 30.1 months, the persistent cCR rate was 79% (30 of 38 patients) in the NOM cohort. The 2-year local regrowth-free survival was 81% (95% confidence interval [CI], 70%-94%) in the initial cCR group, and all patients with local regrowth were successfully salvaged. Compared with those with a non-cCR, patients with a cCR had improved 2-year regional control (98% [95% CI, 93%-100%] vs 85% [95% CI, 74%-97%], P = .02), distant metastasis-free survival (100% [95% CI, 100%-100%] vs 80% [95% CI, 69%-94%], P < .01), disease-free survival (98% [95% CI, 93%-100%] vs 71% [95% CI, 59%-87%], P < .01), and overall survival (100% [95% CI, 100%-100%] vs 88% [95% CI, 79%-98%], P = .02). No late grade 3+ gastrointestinal or genitourinary toxicities were observed in the patients who underwent continued NOM. CONCLUSIONS Short-course radiation therapy followed by consolidation chemotherapy may be a feasible organ preservation strategy in rectal cancer. Additional prospective studies are necessary to evaluate the safety and efficacy of this approach.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Amit Roy
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Katrina S Pedersen
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Steven R Hunt
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Sean C Glasgow
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Benjamin R Tan
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Paul E Wise
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew L Silviera
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Radhika K Smith
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Rama Suresh
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Anup S Shetty
- Section of Abdominal Imaging, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew G Mutch
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri.
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Abstract
INTRODUCTION Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE. MATERIALS AND METHODS Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively. RESULTS There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups (p = .608). No difference was found in major (Clavien-Dindo III-V) complications, but we found statistically significant difference in minor (Clavien-Dindo I-II) complications (p = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant (p = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group (p = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower (p = .018) after ELAPE. DISCUSSION AND CONCLUSIONS In our experience ELAPE operations may diminish the rate of Clavien-Dindo I-II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.
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Affiliation(s)
- Géza Papp
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
| | - Kristóf Dede
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
| | - Attila Bursics
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
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Hamabe A, Okita K, Nishidate T, Okuya K, Akizuki E, Sato Y, Ishii M, Miura R, Korai T, Takemasa I. Transperineal minimally invasive abdominoperineal excision for rectal cancer based on anatomical analysis of the muscular structure. Asian J Endosc Surg 2021; 14:675-683. [PMID: 33561899 DOI: 10.1111/ases.12917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/04/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Transperineal minimally invasive abdominoperineal excision (TpAPE) may help minimize surgical invasiveness and make it possible to perform two-team surgery, although this procedure is regarded as difficult. The anatomical structures are complicated and have not been clearly defined, particularly on the anterior side of the anorectal junction in men. We investigated the anatomical configuration around the anterior wall of the anorectal junction, focusing on the structure of the striated muscles, to establish a standard procedure for TpAPE. METHODS We scrutinized the T2 -weighted MRI scans of 106 men, and two male cadavers were used to examine the muscular structure surrounding the anorectal junction. We established our standardized procedure for TpAPE based on these anatomical studies. We also analyzed the clinicopathological findings from five men who had undergone TpAPE at our institution. RESULTS Using MRI, we detected band-like muscles bilaterally, just medial to the puborectal muscle in all analyzed patients, which we termed the rectal anterolateral muscle. We also detected the muscles that may correspond to the rectal anterolateral muscle when inspecting the cadavers. The standardized TpAPE procedures were carried out uneventfully for the five cases, and intraoperative complications such as urethral injury and inadvertent rectal perforation did not occur. CONCLUSION We standardized the TpAPE procedure based on anatomical examination of the muscular structure around the anal canal. The findings can contribute to safe implementation of TpAPE.
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Affiliation(s)
- Atsushi Hamabe
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Kenji Okita
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Toshihiko Nishidate
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Koichi Okuya
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Emi Akizuki
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Yu Sato
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Masayuki Ishii
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Ryo Miura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Takahiro Korai
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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45
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Zhang GQ, Sahyoun R, Stem M, Lo BD, Rajput A, Efron JE, Atallah C, Safar B. Operative Approach Does Not Impact Radial Margin Positivity in Distal Rectal Cancer. World J Surg 2021; 45:3686-3694. [PMID: 34495388 DOI: 10.1007/s00268-021-06278-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). METHODS This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. RESULTS Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). CONCLUSIONS No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.
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Affiliation(s)
- George Q Zhang
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Sahyoun
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian D Lo
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Koëter T, de Nes LCF, Wasowicz DK, Zimmerman DDE, Verhoeven RHA, Elferink MA, de Wilt JHW. Hospital variation in sphincter-preservation rates in rectal cancer treatment: results of a population-based study in the Netherlands. BJS Open 2021; 5:6325344. [PMID: 34291288 PMCID: PMC8295312 DOI: 10.1093/bjsopen/zrab065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/28/2021] [Indexed: 01/18/2023] Open
Abstract
Background This study aimed to examine the sphincter-preservation rate variations in rectal cancer surgery. The influence of hospital volume on sphincter-preservation rates and short-term outcomes (anastomotic leakage (AL), positive circumferential resection margin (CRM), 30- and 90-day mortality rates) were also analysed. Methods Non-metastasized rectal cancer patients treated between 2009 and 2016 were selected from the Netherlands Cancer Registry. Surgical procedures were divided into sphincter-preserving surgery and an end colostomy group. Multivariable logistic regression models were generated to estimate the probability of undergoing sphincter-preserving surgery according to the hospital of surgery and tumour height (low, 5 cm or less, mid, more than 5 cm to 10 cm, and high, more than 10 cm). The influence of annual hospital volume (less than 20, 20–39, more than 40 resections) on sphincter-preservation rate and short-term outcomes was also examined. Results A total of 20 959 patients were included (11 611 sphincter preservation and 8079 end colostomy) and the observed median sphincter-preservation rate in low, mid and high rectal cancer was 29.3, 75.6 and 87.9 per cent respectively. After case-mix adjustment, hospital of surgery was a significant factor for patients’ likelihood for sphincter preservation in all three subgroups (P < 0.001). In mid rectal cancer, borderline higher rates of sphincter preservation were associated with low-volume hospitals (odds ratio 1.20, 95 per cent c.i. 1.01 to 1.43). No significant association between annual hospital volume and sphincter-preservation rate in low and high rectal cancer nor short-term outcomes (AL, positive CRM rate and 30- and 90-day mortality rates) was identified. Conclusion This population-based study showed a significant hospital variation in sphincter-preservation rates in rectal surgery. The annual hospital volume, however, was not associated with sphincter-preservation rates in low, and high rectal cancer nor with other short-term outcomes.
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Affiliation(s)
- T Koëter
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L C F de Nes
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Surgery, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - D K Wasowicz
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - M A Elferink
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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47
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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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Teste B, Rullier E. Intraoperative complications during laparoscopic total mesorectal excision. Minerva Surg 2021; 76:332-342. [PMID: 33944516 DOI: 10.23736/s2724-5691.21.08691-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intraoperative complication during laparoscopic mesorectal excision for rectal cancer is a common complication occurring in 11% to 15% of the cases. They are probably underestimated because not systematically reported. The most frequent intraoperative complications are haemorrhage (3-7%), tumour perforation (1-4%), bowel injury (1-3%), ureter injury (1%), urogenital injury (2%), other organ injury (<1%), and anastomotic complications (1%). The mechanisms, management and prevention of vascular port injury, inferior mesenteric artery bleeding, small bowel and colon perforation, ureteral and urethral injury, pelvic nerve damage, tumour perforation and anastomotic failure are described. This review underlines the necessity to prevent intraoperative complication to avoid operative death and severe side-effects.
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Affiliation(s)
- Blanche Teste
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France -
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49
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Tripathi P, Hai Y, Li Z, Shen Y, Hu X, Hu D. Morphometric assessment of the mesorectal fat in Chinese Han population: A clinical MRI study. Sci Prog 2021; 104:368504211016214. [PMID: 33960865 PMCID: PMC10364940 DOI: 10.1177/00368504211016214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The study aimed to analyze morphometric assessment of the mesorectal fat thickness and its correlation with body mass index in Chinese Han population. The anterior, posterior, right lateral, and left lateral mesorectal fat thickness were measured using MRI T2-weighted images. The mean distance from the rectal wall to the mesorectal fascia were 3.8, 8.4, 11.3, and 11.7 mm in anterior, posterior, right lateral, and left lateral portion, respectively. The mesorectal area, rectal area, mesorectal fat thickness area, and rectal height were 2395.3 ± 691.1 mm2, 709.6 ± 403.5 mm2, 1685.7 ± 525.3 mm2, and 9.1 ± 0.8 cm. BMI was found to be directly proportional to and statistically significant to the mesorectal fat area (p = 0.01). Since the mean mesorectal fat thickness was found to be <12 mm, T3d staged rectal cancer is less likely to be found in an average Chinese population that may affect the overall-survival and progression-free survival in rectal cancer patients. Anterior portion of the rectum was least thick compared to all other sides. Therefore, extra-caution should be taken in handling tumors on the anterior part of the rectum.
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Affiliation(s)
- Pratik Tripathi
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yucheng Hai
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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50
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Persistent High Rate of Positive Margins and Postoperative Complications After Surgery for cT4 Rectal Cancer at a National Level. Dis Colon Rectum 2021; 64:389-398. [PMID: 33651005 DOI: 10.1097/dcr.0000000000001855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response. OBJECTIVE Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level. DESIGN This is a population-based study. SETTINGS Data were retrieved from the Dutch Colorectal Audit. PATIENTS A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected. MAIN OUTCOME MEASURES Main outcomes were resection margins, postoperative complications, and mortality. RESULTS Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001). LIMITATIONS Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available. CONCLUSIONS This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457. ALTA TASA PERSISTENTE DE MRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUS DE LA CIRUGA DE CNCER RECTAL CTA NIVEL NACIONAL ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.
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