Inadvertent perforation during rectal cancer resection in Norway

Can CT Pelvimetry Be Used to Predict Circumferential Resection Margin Positivity in Laparoscopic Resection of Middle and Lower Rectum Cancer?

Background Previous studies have shown that pelvimetry can be valuable in predicting surgical difficulties in rectal cancer operations. However, its usability in predicting circumferential resection margin (CRM) involvement remains debatable. This study investigated the factors affecting CRM status and the importance of computed tomography (CT) pelvimetry in predicting CRM involvement in laparoscopic resection of middle and lower rectal cancer. Methodology In this study, we retrospectively investigated the data of 111 patients who underwent a laparoscopic operation for middle and lower rectum cancer at Ankara University Faculty of Medicine, Department of Surgical Oncology between January 2014 and January 2020. The predictive value of CT pelvimetry and other variables on the CRM status was analyzed. Results The following four pelvic parameters differed significantly between the genders: transverse diameter of the pelvic inlet (p = 0.024), anteroposterior diameter of the pelvic outlet (p = 0.003), transverse diameter of the pelvic outlet (p < 0.001), and pelvic depth (p < 0.001). The effect of pelvic anatomic parameters on CRM involvement was not found to be significant. It was found that tumor height from the anal verge (p = 0.004), tumor size (p < 0.001), and gender (p = 0.033) were significant risk factors for CRM involvement. Survival was poor in patients with male gender (p = 0.032), perineural invasion (p < 0.001), and grade 3 tumor. Conclusions In this study, no benefit was found in predicting CRM positivity from CT pelvimetry in the laparoscopic resection of middle and lower rectal cancer. Besides, tumor height from the anal verge, tumor size, and gender were important factors for CRM positivity. Although our study sheds light on this issue, prospective randomized studies with larger sample sizes are needed.

The Efficacy of Transanal Total Mesorectal Excision: a Preliminary Vietnamese Report

Introduction:

The e physical anatomical characteristics of Vietnamese people are similar to those of other East Asian populations, with a deep and narrow pelvis but an average body mass index (BMI) among patients at the advanced stage of rectal cancer.

Aim:

This study aimed to prospectively evaluate the short-term outcomes of transanal total mesorectal excision (TaTME) for rectal cancer treatment in a Vietnamese population.

Methods:

A total of 64 patients who underwent TaTME were included in this study. The pelvic anatomical parameters, BMI, operative morbidities, macroscopic qualities of the mesorectal specimens, circumferential resection margins, and anal sphincter functional data were collected. The method popularized by Quirke and Kirwan’s classification were used to assess to quality of the mesorectal specimens and the sphincter function, respectively. Statistical analysis was performed using SPSS 20.0.

Results:

The mean age and BMI of the patients were 66.4 years and 20.5 kg/m2, respectively. Most patients had narrow pelvises, with mean transverse pelvic outlet diameters of 10.12 ±1.85 cm, for males, and 10.43 ± 1.32 cm, for females, and pelvic depths of 12.36 ±2.03 cm, for males, and 11.73 ±1.12 cm, for females. The mean tumor size was 5.17 ±1.62 cm. Among the mesorectal specimens, 82.8% were complete and 14.1% were nearly complete. Disease-free survival and overall survival rates were 98.2% and 100%, respectively. Sphincter functions at 12 months post-operation were rated as 30.8% Kirwan I, 42.3% Kirwan II, and 26.9% Kirwan III.

Conclusion:

TaTME surgery represents a safe and suitable option among Vietnamese patients with narrow and deep pelvises and advanced rectal tumors in the middle third and lower third of the rectum.

Intraoperative complications during laparoscopic total mesorectal excision

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.

A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival

PURPOSE

Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach.

METHODS

This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures.

RESULTS

A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively.

CONCLUSION

Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer

BACKGROUND

Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer.

METHODS

This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage.

RESULTS

A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years.

CONCLUSION

In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.

Impact of rectal perforation on recurrence during rectal cancer surgery in a national population registry

BACKGROUND

Incidental perforation in rectal cancer surgery is considered a risk factor for poorer oncological outcome. Most studies emanate from the era before total mesorectal excision when staging, neoadjuvant treatment and surgical technique were suboptimal. This study assessed the impact of incidental perforation on oncological outcome in a cohort of patients with optimized management.

METHODS

Data from the Swedish Colorectal Cancer Registry for patients undergoing R0 abdominal surgery for TNM stage I-III rectal cancer between 2007 and 2012, with 5-year follow-up, were analysed. Multivariable analysis was performed.

RESULTS

In total, 6176 patients were analysed (208 with and 5968 without perforation). The local recurrence rate was increased after perforation (7·2 per cent (15 of 208) versus 3·2 per cent (188 of 5968); P = 0·001), but there were no differences in rates of distant metastasis (16·3 per cent (34 of 208) versus 19·8 per cent (1183 of 5968); P = 0·215) and overall recurrence (20·7 per cent (43 of 208) versus 21·0 per cent (1256 of 5968); P = 0·897). The 5-year overall survival rate was lower after perforation (66·4 versus 75·5 per cent; P = 0·002), but the 5-year relative survival rate was no different (79·9 versus 88·2 per cent; P = 0·083). In multivariable analysis, perforation was a risk factor for local recurrence (hazard ratio 2·10, 95 per cent c.i. 1·19 to 3·72; P = 0·011), but not for the other outcomes.

CONCLUSION

Incidental perforation remains a significant risk factor for LR, even with optimized management of rectal cancer. This must be considered when discussing adjuvant treatment and follow-up.

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Background

Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME.

Methods

Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence.

Results

The implementation cohort of 120 patients had a median follow up of 21·9 months. Short‐term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre).

Conclusion

TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

Prognostic impact of postoperative intra-abdominal infections after elective colorectal cancer resection on survival and local recurrence: a propensity score-matched analysis

PURPOSE

Several authors have reported an association between anastomotic leak and/or intra-abdominal abscess and oncological survival and recurrence. However, no reports have investigated whether combining anastomotic leak/intra-abdominal abscess and positive drainage culture influences long-term oncological outcomes. Therefore, we defined these complications as postoperative intra-abdominal infections. The present study aimed to evaluate the prognostic impact of postoperative intra-abdominal infections on long-term oncological outcomes after curative stage I-III colorectal cancer surgery.

METHODS

We performed a retrospective analysis of 755 consecutive patients with stage I-III colorectal cancer undergoing curative surgery between 2010 and 2015 by performing a propensity score-matched analysis to reduce selection bias.

RESULTS

Of the 755 patients, 62 were matched for postoperative intra-abdominal infections analyses. The median follow-up was 48 months. Compared with the non-infections group, the postoperative intra-abdominal infections group had a significantly shorter local recurrence-free survival (P = 0.01 prior to matching, and P = 0.05 after matching). No significant difference was found between the groups in terms of overall, cancer-specific free, recurrence-free, or distant recurrence-free survival. However, multivariate analyses identified postoperative intra-abdominal infections as an independent prognostic factor for local recurrence-free survival (P = 0.04 prior to matching, and P = 0.03 after matching).

CONCLUSIONS

In this matched-pair analysis comparing stage I-III colorectal cancer patients with and without postoperative intra-abdominal infections, postoperative intra-abdominal infections were associated with poor local recurrence-free survival, but not overall, cancer-specific free, recurrence-free, or distant recurrence-free survival.

Locally recurrent rectal cancer: what the radiologist should know

Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

Background

Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis^®, Biodesign™) reconstruction following ELAPER.

Methods

A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).

Results

One hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.

Conclusions

This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.

Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

BACKGROUND

Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME).

METHODS

All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated.

RESULTS

In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME.

CONCLUSION

TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.

Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer

INTRODUCTION

Anastomotic leakage is one of the most severe early complications after colorectal surgery, and it is associated with a high reoperation rate-, and increased in short-term morbidity and mortality rates. It remains unclear whether anastomotic leakage is associated with poor oncologic outcomes. The aim of this study was to determine the impacts of anastomotic leakage on long-term oncologic outcomes, disease-free survival and overall mortality in patients who underwent curative surgery for colorectal cancer.

METHODS

This single-centre, retrospective, observational cohort study included patients who underwent curative surgery for colorectal cancer between 2005 and 2015 and who had a primary anastomosis. Survival- and multivariate cox regression analyses were performed to adjust for confounding.

RESULTS

A total of 1984 patients had a primary anastomosis after surgery. The overall incidence of anastomotic leakage was 7.5%; 19 patients were excluded because they were lost to follow-up. Of the remaining 1965 patients, 41 (2.1%) developed local recurrence associated with anastomotic leakage [adjusted hazard ratio (HR) = 2.25; 95% confidence interval (CI) 1.14-5.29; P = 0.03]. Distant recurrence developed in 291(14.8%) patients with no association with anastomotic leakage [adjusted HR = 1.30 (95% CI: 0.85-1.97) P = 0.23]. Anastomotic leakage was associated with increased long-term mortality [adjusted HR = 1.69 (95% CI 1.32-2.18) P < 0.01]. Five year disease-free survival was significantly decreased in patients with anastomotic leakage, (log rank test P < 0.01).

CONCLUSION

Anastomotic leakage was significantly associated with increased rates of local recurrence, disease free-survival and overall mortality. Associations of anastomotic leakage with distant recurrence was not found.

Meta-analysis of histopathological outcomes of laparoscopic assisted rectal resection (LARR) vs open rectal resection (ORR) for carcinoma

BACKGROUND

We conducted a meta-analysis of the randomized evidence to determine the relative merits of histopathological outcomes of laparoscopic assisted (LARR) versus open rectal resection (ORR) for rectal cancer.

DATA SOURCES

A search of PubMed and other electronic databases comparing LARR and ORR between Jan 2000 and June 2016 was performed. Histopathological variables analyzed included; location of rectal tumors; complete and incomplete TME; positive and negative circumferential resection margins (+/-CRM); positive distal resected margins (+DRM); distance of tumor from DRM; number of lymph nodes harvested; resected specimen length; tumor size and perforated rectum.

RESULTS

Fourteen RCTs totaling 3843 patients (LARR = 2096, ORR = 1747) were analyzed. Comparable effects were noted for all these histopathological variables except for the variable perforated rectum which favored ORR.

CONCLUSIONS

LARR compares favorably to ORR for rectal cancer treatment. However, there is significantly higher risk of rectal perforation during LARR compared to ORR.

Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up

PURPOSE

To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival.

METHODS

A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3-4) rectal cancer with APE in 2004-2009 were compared to patients with similar tumors operated with ELAPE in 2009-2016.

RESULTS

Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups.

CONCLUSIONS

We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.

Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer

Treatment results in rectal cancer have improved significantly during the recent two decades, but local control and survival after abdominoperineal excision (APE) have not improved to the same degree as that seen after anterior resection (AR). The reason for this is an increased risk of inadvertent bowel perforations and tumor involved margins after APE as compared with AR. The conventional synchronous combined APE has not been a standardized procedure and consequently oncological outcomes have varied considerably between different institutions and in different reports. With the new concept of APE, based on well-defined anatomical structures, the procedure can be categorized as intersphincteric APE, extralevator APE, and ischioanal APE. This article discusses the technical aspects and results from this approach.

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: Long-term outcomes of a propensity score matched study

BACKGROUND AND OBJECTIVES

Laparoscopic resection for rectal cancer has short-term benefits when compared to open resection. The aim of this study was to compare the long-term oncological outcomes of laparoscopic and open resection for rectal cancer following neoadjuvant chemoradiation (NCRT).

METHODS

In this propensity matched study, a series of 72 patients who underwent laparoscopic surgery for rectal cancer following NCRT between 2004 and 2010 (Lap group) were matched with 72 patients who underwent open surgery for rectal cancer in the same period (Open group). The survival and recurrence patterns were compared between the two groups.

RESULTS

After a median follow-up of 69.5 months (range 1-138 months), local recurrence rate was observed in 4 patients (5.5%) and 7 patients (9.7%) in the Lap and Open groups, respectively (P = 0.35). The 5- and 10-year disease-free survival in the Lap and Open groups were 61.3% versus 47.9% and 48.8% versus 41%, respectively (P = 0.16). The 5- and 10-year overall survival was 66.9% versus 60.2% and 49% versus 46.2% in the Lap and Open groups, respectively (P = 0.38).

CONCLUSION

Laparoscopic surgery following NCRT for low and mid third rectal cancers was associated with similar long-term oncological outcomes when compared to open surgery.

A systematic review of transabdominal levator division during abdominoperineal excision of the rectum (APER)

BACKGROUND

The aim of the present study was to evaluate the surgical technique, short-term oncological and perioperative outcomes for the transabdominal division of the levator ani muscles during abdominoperineal excision of the rectum (APER).

METHODS

A systematic review was performed to identify studies reporting on transabdominal division of the levator ani during APER. A comprehensive literature search was performed using a combination of free-text terms and controlled vocabulary when applicable on the following databases: MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library. The search period was from January 1945 to December 2015. The following search headings were used: "transabdominal", "transpelvic", "abdominal" or "pelvic" combined with either "levator" or "extralevator" and with "abdominoperineal".

RESULTS

Nine publications were identified reporting on 99 participants. The male/female distribution was 1.44:1, respectively, and the mean age was 56.6 (30-77) years. All tumours were less than 5 cm from the anal verge. The preoperative radiological staging was T2 in 18% of cases, T3 in 53.5% and T4 in 28.5%. Transabdominal division of the levators was performed laparoscopically in 55 cases, robotically in 34 and open in 10. The mean operating time was 255 (177-640) min. Mean intraoperative blood loss was 140 (92-500) ml. There were no conversions to open. Circumferential resection margins were positive in two cases, and there was one intraoperative perforation. Mean post-operative length of stay was 9.3 (3-67) days. Follow-up (from 0 to 31 months) revealed 19 perineal wound infections, 15 cases of sexual dysfunction and 7 cases of urinary retention. There was no mortality and 1 readmission.

CONCLUSIONS

Transabdominal division of the levators during APER is feasible and reproducible, with acceptable perioperative and good early oncological outcomes. Further comparative studies are needed.

A pilot randomized study comparing extralevator with conventional abdominoperineal excision for low rectal cancer after neoadjuvant chemoradiation

AIM

The aims of this study were to assess the feasibility of performing an extralevator abdominoperineal excision (ELAPE) after neoadjuvant chemoradiation (NCRT), to compare the rates of circumferential resection margin (CRM) involvement and intra-operative perforation (IOP) of the specimen, and to assess the amount of tissue removed around the muscularis propria (MP)/internal sphincter (IS) of the lower rectum in patients with low rectal cancer undergoing ELAPE compared with conventional abdominoperineal excision (CAPE) after NCRT.

METHOD

This was an open-label, parallel-arm pilot randomized trial conducted in India. Twenty patients were randomized to one of the study arms. The surgical specimens were fixed, serially cross-sectioned and photographed. Using specialized morphometry software, the amount of tissue resected with each operation was measured.

RESULTS

There was a nonsignificant trend towards more IOPs (30% vs 0%, P = 0.06) and a higher CRM involvement rate (40% vs 20%, P = 0.32) in the CAPE arm. ELAPE removed a significantly greater amount of tissue around the IS/MP when compared with CAPE (mean ± SD: 1911.39 ± 382 mm² vs 1132.03 ± 371 mm² , P < 0.001). The mean distance from the IS/MP to the CRM was significantly greater in the ELAPE arm both in the posterior (mean ± SD: 28.28 ± 3 mm vs 9.63 ± 3 mm, P < 0.001) and lateral (mean ± SD: 13.69 ± 3 mm vs 9.72 ± 3 mm, P = 0.009) parts of the rectum but not in the anterior part (mean ± SD: 6.74 ± 2 mm vs 6.10 ± 4 mm, P = 0.64). The short-term morbidity was not significantly different between the two procedures.

CONCLUSION

ELAPE removed more tissue in the lower rectum and resulted in a lower rate of IOP and CRM involvement when compared with CAPE, even after NCRT.

Prospective multicenter registration study of colorectal cancer: significant variations in radicality and oncosurgical quality-Swiss Group for Clinical Cancer Research Protocol SAKK 40/00

PURPOSE

This study aimed to investigate in a multicenter cohort study the radicality of colorectal cancer resections, to assess the oncosurgical quality of colorectal specimens, and to compare the performance between centers.

METHODS

One German and nine Swiss hospitals agreed to prospectively register all patients with primary colorectal cancer resected between September 2001 and June 2005. The median number of eligible patients with one primary tumor included per center was 95 (range 12-204).

RESULTS

The following variations of median values or percentages between centers were found: length of bowel specimen 20-39 cm (25.8 cm), maximum height of mesocolon 6.5-12.5 cm (9.0 cm), number of examined lymph nodes 9-24 (16), distance to nearer bowel resection margin in colon cancer 4.8-12 cm (7 cm), and in rectal cancer 2-3 cm (2.5 cm), central ligation of major artery 40-97 % (71 %), blood loss 200-500 ml (300 ml), need for perioperative blood transfusion 5-40 % (19 %), tumor opened during mobilization 0-11 % (5 %), T4-tumors not en-bloc resected 0-33 % (4 %), inadvertent perforation of mesocolon/mesorectum 0-8 % (4 %), no-touch isolation technique 36-86 % (67 %), abdominoperineal resection for rectal cancer 0-30 % (17 %), rectal cancer specimen with circumferential margin ≤1 mm 0-19 % (10 %), in-hospital mortality 0-6 % (2 %), anastomotic leak or intra-abdominal abscess 0-17 % (7 %), re-operation 0-17 % (8 %).

CONCLUSION

In colorectal cancer, surgery considerable variations between different centers were found with regard to radicality and oncosurgical quality, suggesting a potential for targeted improvement of surgical technique.

Extralevator abdominoperineal excision versus conventional surgery for low rectal cancer: a single surgeon experience

OBJECTIVE

Extralevator abdominoperineal excision (ELAPE) reduces the risk of positive circumferential resection margin (CRM) and of intraoperative perforation (IOP), both of which are associated with high local recurrence rates and poor survival outcomes for rectal cancer. The aim of this study was to compare the results of ELAPE with conventional abdominoperineal excision (APE) for low rectal cancer.

MATERIAL AND METHODS

A total of 25 consecutive patients underwent ELAPE for low rectal cancer between November 2008 and September 2011. Fifty-six patients treated by conventional APE prior to 2008 were selected from our rectal cancer database for comparison as a historical cohort.

RESULTS

The mean follow-up was 44.7 months in the ELAPE group, and 70.6 months in the APE group. Patients undergoing ELAPE had a lower CRM positivity and IOP rate than APE (12% vs. 20%, p=0,531; 4% vs. 8,9%, p=0,826; respectively). The ELAPE group was associated with higher perineal wound complications than the APE group (16.0% vs. 1.8%, p=0.030). Local recurrence rates for patients in both groups did not differ significantly (4.0% vs. 3.6%, p=1.0).

CONCLUSION

The results of this study suggest that ELAPE technique was associated with less CRM involvement and reduced rates of IOP but markedly higher rates of postoperative perineal complications occurred as compared to conventional surgery. ELAPE must be reserved for advanced low rectal cancers.

Recent surgical advances in colorectal cancer excision: toward optimal outcomes

Colorectal cancer is the third most common cancer affecting both males and females in the western world. Despite all the developments in the current treatment of colorectal cancer, it is still continuing to be an important factor of patient morbidity and mortality worldwide. Surgery is the mainstay of treatment for colorectal cancer. Over the last decade, there have been major changes and developments in the surgical treatment. Understanding the importance of the anatomy, technological advances in minimally invasive surgery and effects of chemoradiotherapy have changed the approaches to colorectal cancer treatment. Today, novel treatment strategies must be targeted not only minimally invasive approaches, but also aiming to increase patients’ quality of life without compromising the oncological principles.

Extralevator abdominoperineal excision (Elape): A retrospective cohort study

INTRODUCTION

Extralevator abdominoperineal excision (ELAPE) is relatively new surgical technique for low rectal cancers. It is a more radical approach than conventional abdominoperineal excision (APE) with potentially better oncological outcome. The aim of this study was to analyse short term results of ELAPE compared with conventional abdominoperineal excision.

METHODS

Data were collected prospectively for 72 patients who underwent abdominoperineal excision (APE) for low rectal carcinomas from 2010 to 2014. Of these 24 patients underwent ELAPE with biological prosthetic mesh used to close the perineal defect.

RESULTS

The median age of patients was 68 (37-87). Positive circumferential resection margin (1/24 vs. 8/48) and Intra operative perorations (0/24 vs. 6/48) compared favourably with ELAPE.

CONCLUSIONS

Short term results from this study support that ELAPE has better oncological outcome.

Impact of anastomotic leakage on long-term oncologic outcome and its related factors in rectal cancer

Anastomotic leakage (AL) is a well-known cause of morbidity after low anterior resection (LAR) for rectal cancer, but its impact on oncologic outcome is not well understood. The aim of this study is to investigate the impact of AL on long-term oncologic outcome and to identify factors associated with AL that may affect prognosis after LAR for rectal cancer.A retrospective analysis of patients who underwent curative resection for rectal cancer without diverting stoma was performed. To investigate AL related factors that may be associated with oncologic outcome, Clavien-Dindo grades, prognostic nutritional indices (PNI) and inflammatory indices were included.One hundred and one patients out of a total of 1258 patients developed postoperative AL, giving an AL rate of 8.0%. Patients with AL showed poorer disease-free survival (DFS), than patients without AL (hazard ratio [HR] = 1.6; 95% confidence intervals [CI]: 1.1-2.5; P = 0.01). In patients who developed AL, age over 60 (HR = 2.2; 95% CI: 1.1-4.7; P = 0.033), advanced pathologic stage (HR = 2.4; 95% CI: 1.4-4.0; P = 0.001), suppressed neutrophil-proportion (≤80%) (HR = 2.6; 95% CI: 1.2-5.8; P = 0.019) and PNI <36 (HR = 3.5; 95% CI: 1.2-9.6; P = 0.018) were associated with poorer DFS.AL was associated with poorer DFS. In patients with AL, a suppressed neutrophil-proportion and decreased PNI below 36 were associated with tumor recurrence.

Management of the Perineal Defect after Abdominoperineal Excision

The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.

Circumferential resection margins and perineal complications after neoadjuvant long-course chemoradiotherapy followed by extralevator abdominoperineal excision of the rectum: Five years of activity at a single institution

BACKGROUND

Prone extralevator abdominoperineal excision of the rectum (ELAPE) has been introduced to improve the circumferential resection margins (CRM) compared with traditional APER.

OBJECTIVE

We present short-term results achieved with prone ELAPE preceded by neoadjuvant chemoradiotherapy during the last 5 years of activity.

DESIGN

A retrospective review was conducted.

SETTINGS AND PATIENTS

Prone ELAPE operations performed between September 2010 and August 2014 at Leicester Royal Infirmary preceded by neoadjuvant chemoradiotherapy.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Data regarding demographics, staging, neoadjuvant therapies, intraoperative perforations, and perineal complications were collected.

RESULTS

Seventy-two patients were included. Pretreatment radiological T4 were 25.0%, histological T4 2.8%. Intraoperative perforations occurred in 2.8%, CRM was involved in 11.1%. Perineal complications consisted of superficial wound infections (20.8%), full thickness dehiscences (16.7%), hematomas (9.7%), pelvic collections (6.9%), and perineal hernias (5.6%).

CONCLUSIONS

In our experience, prone ELAPE preceded by long-course chemoradiotherapy has been successfully used in the last 5 years to resect low rectal tumors. Perineal wound complications rates are similar to those presented in series using direct perineal closures. J. Surg. Oncol. 2016;114:86-90. © 2016 Wiley Periodicals, Inc.

Definition and clinical significance of tumour rupture in gastrointestinal stromal tumours of the small intestine

BACKGROUND

Tumour rupture is a risk factor for recurrence of gastrointestinal stromal tumour (GIST). In this study, patterns of recurrence after potential tumour seeding were investigated, and a new definition of tumour rupture, based on major and minor defects of tumour integrity, is proposed.

METHODS

Patients undergoing surgery for non-metastatic small intestinal GIST from 2000 to 2012 were included in the study. Tumour spillage, tumour fracture or piecemeal resection, bowel perforation at the tumour site, blood-tinged ascites, microscopic tumour infiltration into an adjacent organ, and surgical biopsy were defined as major defects of tumour integrity. Peritoneal tumour penetration, iatrogenic peritoneal laceration and microscopically involved margins were defined as minor defects.

RESULTS

Seventy-two patients were identified. Median follow-up was 58 (range 7-122) months. Radical surgery was performed in 71 patients. A major defect was recorded in 20 patients, and a minor defect in 21. The 5-year recurrence rate was 64, 29 and 31 per cent in patients with major, minor and no defect respectively (P = 0·001). The hazard ratio (HR) for major defect versus no defect was 3·55 (95 per cent c.i. 1·51 to 8·35). Peritoneal recurrence rates for major, minor and no defect were 52, 25 and 19 per cent respectively (P = 0·002), and the HR for major defect versus no defect was 4·98 (1·69 to 14·68). On multivariable analysis, mitotic index, major defect of tumour integrity, tumour size and age were independently associated with risk of recurrence.

CONCLUSION

Recurrence rates were increased after major, but not minor tumour ruptures.

Dynamic Article: Tandem Robotic Technique of Extralevator Abdominoperineal Excision and Rectus Abdominis Muscle Harvest for Immediate Closure of the Pelvic Floor Defect

BACKGROUND

Extralevator abdominoperineal excision for distal rectal cancers involves cylindrical excision of the mesorectum with wide division of the levator ani muscles. Although this technique has been shown to decrease local cancer recurrence and improve survival, it leaves the patient with a considerable pelvic floor defect that may require reconstruction.

OBJECTIVE

We developed an innovative technique of robotic extralevator abdominoperineal excision combined with robotic harvest of the rectus abdominis muscle flap for immediate reconstruction of the pelvic floor defect.

DESIGN

This was a retrospective review pilot study.

SETTING

This study was conducted at a tertiary care cancer center.

PATIENTS

Three patients who underwent robotic extralevator abdominoperineal excision with robotic rectus abdominis flap harvest for distal rectal adenocarcinoma were included.

MAIN OUTCOMES MEASURES

Intraoperative and postoperative outcomes included operative time, intraoperative complications, length of hospital stay, wound complications, incidence of perineal hernia, persistent pain, and functional limitations.

RESULTS

Three patients underwent this procedure. The median operative time was 522 minutes with median hospital stay of 6 days. One patient experienced perineal wound complication requiring limited incision and drainage followed by complete healing of the wound by secondary intention. The other 2 patients did not experience any wound complications. Longest follow-up was 16 months. None of the patients developed perineal hernias during this time period.

LIMITATIONS

The small sample size and retrospective nature were limitations.

CONCLUSIONS

This technique confers multiple advantages including improved visualization and dexterity within the pelvis and accurate wide margins at the pelvic floor. An incisionless robotic flap harvest with preservation of the anterior rectus sheath obviates the risk of ventral hernia while providing robust tissue closure of the radiated abdominoperineal excision wound. This technique may result in faster postoperative recovery, decreased morbidity, improved functional outcomes and cosmesis. Further studies are needed to prospectively analyze this approach (Supplemental Digital Content 1, video abstract, http://links.lww.com/DCR/A188).

Short-term outcomes of the modified extralevator abdominoperineal resection for low rectal cancer (with videos)

BACKGROUND

Extralevator abdominoperineal resection had oncologic superiority with reduced local recurrence and improving survival rates. However, extended perineal resection resulted in complicated perineal reconstructions. Therefore, a new surgical technique to overcome previous limitations is required. This study aims to demonstrate a surgical procedure and outcomes of the modified extralevator abdominoperineal resection, which satisfies both an extended cylindrical resection and a convenient perineal wound closure by modification of the surgical dissection plane.

METHODS

From September 2011 to February 2014, 12 consecutive patients (five males and seven females) who underwent the modified extralevator abdominoperineal resection for low rectal cancer were evaluated. Intraoperative and postoperative outcomes were assessed. Pathologic outcomes were evaluated for the oncologic results.

RESULTS

The mean age was 55.3 ± 15.1 years, and body mass index was 21.8 ± 3.1 kg/m(2). Ten patients (83.3%) received preoperative chemoradiotherapy. The operations were performed by five cases of laparoscopic surgery, six cases of open surgery and one case of robotic surgery. The mean operation time was 258.8 ± 58.0 min. There were no conversions and no tumor perforations. Days to first soft diet was 4.7 ± 3.4 days, and the mean hospital stay was 11.2 ± 4.7 days. Postoperative complications were two cases of grade I, two cases of grade II and one case of grade III. There was one patient (8.3%) with a positive circumferential resection margin, and there was one case of local recurrence.

CONCLUSIONS

The modified extralevator abdominoperineal resection was feasible and safe for patients with low rectal cancer with extended perineal dissection and convenient direct wound closure.

Analysis of the prognostic factors for low rectal cancer with the pT1-2NxM0 stage after abdominoperineal resection

OBJECTIVE

This study was designed to explore the factors influencing local recurrence and survival for low rectal cancer with pT1-2NxM0 stage after an abdominoperineal resection (APR).

METHODS

Data of 429 patients confirmed to have pT1-2NxM0 after APR were reviewed.

RESULTS

The recurrence rate in patients with intraoperative perforation, less than 12 lymph nodes (LNs) harvested, T2 staging, and positive circumferential resection margin (CRM) was 25.1, 19.9, 9.5, and 26.1% compared with 6.9, 7.0, 0, and 5.8% in patients with no perforation, 12 or more LNs harvested, T1, and negative CRM. The 5-year survival rate in patients with age of at least 70, perforation, less than 12 LNs harvested, T2, and positive CRM was 71.1, 60.8, 58.8, 69.9, and 46.0%, but 73.4, 73.5, 73.8, 89.4, and 75.0% in patients with age less than 70, no perforation, 12 or more LNs harvested, T1, and negative CRM. Meanwhile, patients with N0, N1, and N2 had a survival rate of 90.7, 69.9, and 63.9%. Multivariate analysis showed that perforation (P<0.001), number of LNs harvested (P<0.001), T staging (P<0.001), differentiation (P=0.045), and CRM status (P=0.002) were associated with local recurrence, whereas age of the patients (P=0.023), N staging (P<0.001), differentiation (P=0.011), and CRM status (P=0.004) were associated with survival.

CONCLUSION

APR was affected by patients' age, operation performer, perforation, number of LNs harvested, T staging, N staging, differentiation, and CRM status. Perforation, number of LNs harvested, T staging, differentiation, and CRM status were independent factors for recurrence; meanwhile, age of the patients, N staging, differentiation, and CRM status were independent factors influencing survival.

Response to pathological processes in the peritoneal cavity--sepsis, tumours, adhesions, and ascites

The peritoneum is one of the commonest sites for pathological processes in pediatric surgery. Its response to pathological processes is characterized by an inflammatory reaction with specific pathways depending on the type of injury or peritoneal process involved. This review discusses the current understanding of peritoneal inflammation, adhesion formation, intra-abdominal sepsis, peritoneal metastasis, and ascites and briefly reviews new therapeutic strategies to treat or prevent these pathological entities. Recent studies have improved the understanding of peritoneal responses, resulting in possible new targets for prevention and therapy.

A Comparative Study of Single-Port Laparoscopic Surgery Versus Robotic-Assisted Laparoscopic Surgery for Rectal Cancer

INTRODUCTION

Conventional laparoscopic surgery is the treatment of choice for many abdominal procedures. To further reduce surgical trauma, new minimal invasive procedures such as single-port laparoscopic surgery (SPLS) and robotic assisted laparoscopic surgery (RALS) have emerged. The aim of this study was to compare the early results of SPLS versus RALS in the treatment of rectal cancer.

METHODS

We performed a retrospective analysis of prospectively collected data on patients who had undergone SPLS (n = 36) or RALS (n = 56) in the period between 2010 and 2012. Operative and short-term oncological outcomes were compared.

RESULTS

The RALS group had fewer patients with low rectal cancer and more patients with mid-rectal tumors (P = .017) and also a higher rate of intraoperative complications (14.3% vs 0%, P = .021). The rate of postoperative complications did not differ (P = .62). There were no differences in circumferential resection margins, distal resection margins, or completeness of the mesorectal fascia. The RALS group had a larger number of median harvested lymph nodes (27 vs 13, P = .001). The SPLS group had fewer late complications (P = .025). There were no locoregional recurrences in either of the groups. There was no difference in median follow-up time between groups (P = .58).

CONCLUSION

Both SPLS and RALS may have a role in rectal surgery. The short-term oncological outcomes were similar, although RALS harvested more lymph nodes than the SPLS procedure. However, SPLS seems to be safer with regard to intraoperative and late postoperative complications.

Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment

PURPOSE

Intensified treatment for distal rectal cancer has improved oncological outcome, but at the expense of more perineal wound complications in patients undergoing an abdominoperineal resection (APR). The aim of this study was to analyse perineal wound healing after APR with primary perineal wound closure over time.

METHOD

All patients undergoing APR for primary rectal cancer with primary wound closure between 2000 and 2013 were included and analysed in three consecutive time periods. Both early (<30 days postoperatively) and late perineal wound complications were determined. Independent risk factors of early perineal wound complications were identified using multivariable analysis.

RESULTS

A total of 136 patients were identified, of whom 129 patients underwent primary perineal wound closure. The use of neo-adjuvant (chemo)radiotherapy increased from 72 to 91%, and the use of an extralevator approach increased from 9 to 19%. The rate of early perineal wound complications increased from 18 to 31% and was independently associated with an extralevator approach [odds ratio (OR) 3.17; 95% confidence interval (CI) 1.16-8.66] and intra-operative perforation (OR 3.35; 95% CI 1.06-10.57). Perineal wound complications had no impact on local recurrence or 3-year overall survival rate. During a median follow-up of 28 months [interquartile range (IQR) 14-56], a persistent presacral sinus was diagnosed in 10%, and a perineal hernia occurred in 8% of the patients.

CONCLUSION

The increased use of an extralevator APR for rectal cancer significantly increased the risk of perineal wound complications over time. Intra-operative perforation was also independently associated with impaired perineal wound healing.

Prone extralevator abdominoperineal excision of the rectum with porcine collagen perineal reconstruction (Permacol™): high primary perineal wound healing rates

PURPOSE

Extralevator abdominoperineal excision of the rectum (elAPER) is arguably the modern surgical approach to low rectal cancer and yet results in large defects that may necessitate plastic surgical reconstruction. This study aims to evaluate the quality of prone elAPER surgery with Permacol™ repair of the perineum. The primary end point studied was the rate of primary perineal wound healing.

METHODS

Data were prospectively collected for consecutive patients having prone elAPER at a single institution to assess surgical morbidity together with pathological and cancer-specific outcomes.

RESULTS

Between 2006 and 2012, 48 patients had prone elAPER with median age of 63 (40-86). Thirty-four patients (72.3%) received neoadjuvant treatment. Median length of stay was 9 days (6-66). With a prone approach, three patients had specimen perforation (6.4%) and seven patients had circumferential margin involvement (14.9%). Complete perineal wound healing was achieved in 34 patients (73.9%) at 4 weeks. Four patients (8.3%) were unhealed at 6 months; one patient required a perineal sinus to be laid open, and another patient required plastic surgical reconstruction. No perineal wound herniae have been identified during follow-up.

CONCLUSIONS

Acceptable oncological outcomes are achieved with the prone extralevator approach. The technique achieves high rates of primary healing, making it an attractive option in centres without access to plastic reconstructive expertise.

Controversies in abdominoperineal excision

Abdominoperineal excision (APE) is a necessary operation in many patients with low rectal cancer. Outcomes after this procedure, however, have been variable and often suboptimal. With a new concept of APE, three different types of procedures can be described, based on pelvic and pelvic floor anatomy: intersphincteric APE, extralevator APE (ELAPE), and ischioanal APE. Improved outcomes have been reported after ELAPE but the concept is still controversial and there are disagreements related to the extent of pelvic floor removal, positioning of the patient, and methods of pelvic floor reconstruction.

Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer

AIM

Conventional, synchronous combined, abdominoperineal excision (APE) for low rectal cancer is associated with intra-operative tumour perforation and tumour involvement of the circumferential resection margin (CRM+). Several studies have demonstrated worse rates of local recurrence and survival after APE than after low anterior resection (LAR). Extralevator APE (ELAPE) in the prone position may reduce the risk of perforation and involvement of resection margins and may therefore improve outcome. The aim of this study was to report the outcome after the introduction of ELAPE in a prospective study of consecutive patients from a single colorectal unit.

METHOD

Between January 2000 and March 2013, 193 patients with low rectal cancer were treated with ELAPE at the Karolinska University Hospital, Stockholm, Sweden. All patients were recorded in the regional rectal cancer quality registry, where data on treatment and follow-up are prospectively reported.

RESULTS

Preoperative staging with MRI assessed the tumour to be locally advanced (mrT4) in 126 (65%) of the 193 patients. The median tumour level above the anal verge was 3 cm. Intra-operative perforation occurred in 19 patients (10%) and histopathology revealed a positive CRM in 39 patients (20%). Until August 2013 [median follow-up 31 (0-156) months] local recurrence was detected in 12 patients. Five-year cancer specific survival was estimated to 68%.

CONCLUSION

Good local control and survival may be achieved with ELAPE in patients with low, advanced rectal cancer.

Association between irrigation fluids, washout volumes and risk of local recurrence of anterior resection for rectal cancer: a meta-analysis of 427 cases and 492 controls

BACKGROUND

Rectal washout can prevent local recurrence after anterior resection of rectal cancer. Few studies have focused particularly on the association between irrigation fluids volume or agents and the risk of local recurrence after anterior resection of rectal cancer.

OBJECTIVE

To estimate the association between irrigation fluids types, volumes of rectal washout and risk of local recurrence after anterior resection for cancer.

DATA SOURCES

Relevant studies were identified by a search of Medline, Embase, Wiley Online Library, China National Knowledge Infrastructure, Cochrane Oral Health Group Specialized Register, Wanfang databases and Google Website from their inception until October 18,2013.

STUDY SELECTION

Studies reporting the association between rectal washout types and volumes and risk of local recurrence after anterior resection for cancer were included.

INTERVENTIONS

Eligible studies used rectal washout. Control groups were defined as no washout.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects model were used to obtain summary estimates of RR and 95% CI, with Stata version 11 and RevMan 5.2.5 softwares used. The quality of report was appraised in reference to the MINORS item.

RESULTS

Of the 919 rectal cancer patients in 8 included studies, a total of 61(6.64%) cases of local recurrence were reported, with a pooled RR 0.51 (95%CI = 0.28-0.92, P = 0.03). The RRs 0.37 and 0.39 in normal saline and washout volume (≥ 1500 ml normal saline) subgroup, respectively, indicated that rectal washout with normal saline, or ≥ 1500 ml in volume could significantly reduce local recurrence (LR) rate (95% CI = 0.17-0.79, P = 0.01; 95% CI = 0.18-0.87, P = 0.02) after anterior resection for cancer.

LIMITATION

The included studies were non-randomized observational studies, with diversity of study designs.

CONCLUSION

Rectal washout with normal saline alone can reduce the risk of local recurrence in patients with resectable rectal cancer, and 1.5 liters rectal washout in volume is recommended.

Association between irrigation fluids, washout volumes and risk of local recurrence of anterior resection for rectal cancer: a meta-analysis of 427 cases and 492 controls

BACKGROUND

Rectal washout can prevent local recurrence after anterior resection of rectal cancer. Few studies have focused particularly on the association between irrigation fluids volume or agents and the risk of local recurrence after anterior resection of rectal cancer.

OBJECTIVE

To estimate the association between irrigation fluids types, volumes of rectal washout and risk of local recurrence after anterior resection for cancer.

DATA SOURCES

Relevant studies were identified by a search of Medline, Embase, Wiley Online Library, China National Knowledge Infrastructure, Cochrane Oral Health Group Specialized Register, Wanfang databases and Google Website from their inception until October 18,2013.

STUDY SELECTION

Studies reporting the association between rectal washout types and volumes and risk of local recurrence after anterior resection for cancer were included.

INTERVENTIONS

Eligible studies used rectal washout. Control groups were defined as no washout.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects model were used to obtain summary estimates of RR and 95% CI, with Stata version 11 and RevMan 5.2.5 softwares used. The quality of report was appraised in reference to the MINORS item.

RESULTS

Of the 919 rectal cancer patients in 8 included studies, a total of 61(6.64%) cases of local recurrence were reported, with a pooled RR 0.51 (95%CI = 0.28-0.92, P = 0.03). The RRs 0.37 and 0.39 in normal saline and washout volume (≥ 1500 ml normal saline) subgroup, respectively, indicated that rectal washout with normal saline, or ≥ 1500 ml in volume could significantly reduce local recurrence (LR) rate (95% CI = 0.17-0.79, P = 0.01; 95% CI = 0.18-0.87, P = 0.02) after anterior resection for cancer.

LIMITATION

The included studies were non-randomized observational studies, with diversity of study designs.

CONCLUSION

Rectal washout with normal saline alone can reduce the risk of local recurrence in patients with resectable rectal cancer, and 1.5 liters rectal washout in volume is recommended.

Intra-operative perforation: a risk factor for prognosis of low rectal cancer after abdominoperineal resection

This study was designed to explore the influence of intra-operative perforation on prognosis of low rectal cancer after APR and to investigate the risk factors of perforation. Perforation is not scarce during the procedure of abdominoperineal resection (APR). There is no consensus on perforation rate and related risk factor for APR. Data of 925 patients who received APR for low rectal cancer between January 2000 and August 2008 were reviewed. The intra-operative perforation rate was 7.4 % (68/925). The recurrence rate was 28.6 % in patients with intra-operative perforation compared with 6.8 % in patients with no perforation (P < 0.001); 5-year survival rate in patients with perforation was 41.4 and 66.3 % in patients with no perforation. Univariate analysis showed that intra-operative perforation affected recurrence rate and survival significantly (P < 0.001, P < 0.001); multivariate analysis revealed that intra-operative perforation was an independent prognostic factors for recurrence (RR: 3.087, P < 0.001), while not for survival (RR: 1.331, P = 0.051). Patients aged more than 70 years, T3 tumor and treated by general surgeon had higher perforation rate (P = 0.001, P = 0.004, P = 0.008). Intra-operative perforation affected the prognosis of low rectal cancer after APR significantly. Elderly patient aged more than 70 years, T3 tumor and general surgeon who performed operation were three risk factors of increased perforation rate.

Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis

PURPOSE

Whether the introduction of extralevator abdominoperineal excision (ELAPE) improves survival and safety remains controversial. We conducted a systematic review and meta-analysis of all comparative studies to define the efficacy and safety of ELAPE and standard abdominoperineal excision (APE).

MATERIALS AND METHODS

A search for all major databases and relevant journals from inception to July 2013 without restriction on languages or regions was performed. Outcome measures were the oncological parameters of circumferential resection margin (CRM) involvement, intraoperative bowel perforation (IOP), and local recurrence, as well as other parameters of blood loss, operative time, length of hospitalization, and postoperative complication. The test of heterogeneity was performed with the Q statistic.

RESULTS

A total of 949 patients were included in the meta-analysis. Oncological pooled estimates of intraoperative bowel perforation rate (RR 0.34; 95 % CI 0.21-0.54; P < 0.00001), CRM involvement (RR 0.44; 95 % CI 0.34-0.56; P < 0.00001), and local recurrence (RR 0.32; 95 % CI 0.14-0.74; P = 0.008) all showed outcomes that were significantly lower in ELAPE than in APE. A similar incidence of postoperative complication was attributed to both groups, including overall complication (RR 0.93; 95 % CI 0.66-1.32; P = 0.69), perineal wound complication (RR 0.72; 95 % CI 0.33-1.55; P = 0.39), and urinary dysfunction (RR 1.53; 95 % CI 0.88-2.67; P = 0.13).

CONCLUSION

ELAPE has a lower intraoperative bowel perforation rate, positive CRM rate, and local recurrence rate than APE. There is evidence that in selected low rectal cancer patients, ELAPE is a more efficient and equally safe option to replace APE. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion.

Systematic review and meta-analysis of rectal washout on risk of local recurrence for cancer

BACKGROUND

It has been shown that intraluminal washout (WO) can prevent local recurrence (LR) of rectal cancer. This meta-analysis was to evaluate the association of rectal WO and the risk of LR after anterior resection in patients with rectal cancer.

METHODS

The relevant studies were identified by a search of the MEDLINE, Embase, Wiley Online Library, and Cochrane Oral Health Group Specialized Register with no restrictions on October 18, 2013, and these studies were included in a systematic review and meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in fixed effects model.

RESULTS

A total of nine studies were included in our study, yielding a total of 5519 patients, and pooled ORs for overall LR in corresponding subgroups were calculated. Rectal WO was associated with a lower risk for LR (240/4176, 5.75% versus 9.75%, 131/1343, OR = 0.53, 95% CI = 0.42-0.68, and P < 0.00001) in patients with anterior resection, having total mesorectal excisions (234/3942, 5.93% versus 9.34%, 97/1039, OR = 0.59, 95% CI = 0.46-0.75, and P < 0.00001), and after radical resection (RR; 122/2665, 4.99% versus 8.90%, 74/831, OR = 0.56, 95% CI = 0.41-0.78, and P = 0.0005), with an overall LR rate of 6.72% (371/5519). But, the stability of RRs is not high in the total mesorectal excisions or RR subgroup by sensitivity analysis.

CONCLUSIONS

The use of rectal WO decreases risks of LR in patients after anterior resection of cancer.

Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER)

BACKGROUND

Extra-levator abdominoperineal excision of the rectum (ELAPER) for low rectal cancer is used to avoid the adverse oncological outcomes of inadvertent perforation and a positive circumferential resection margin associated with the conventional APER technique. This wider excision creates a large defect requiring pelvic floor reconstruction, and there is still controversy regarding the best method of closure. The aim of this study is to present outcomes of biological mesh pelvic floor reconstruction following ELAPER.

METHODS

Prospective data on consecutive patients having ELAPER for low rectal cancer at a single UK institution between October 2008 and March 2013 were collected. The perineum was reconstructed using a biological mesh and the short-term outcomes were evaluated, focusing particularly on perineal wound complications and perineal hernias.

RESULTS

Thirty-four patients were included [median age 62 years, range 40-72 years, 27 males (79 %)]. The median operative time was 248 min (range 120-340 min). The median length of hospital stay was 9 days (range 4-20 days). There were three perineal complications (9 %) requiring surgical intervention, but no meshes were removed. There were no perineal hernias. The median length of follow-up was 21 months (range 1-54 months). The overall mortality was 9 % from distant metastases.

CONCLUSIONS

Our series adds to the increasing evidence that good outcomes can be achieved for pelvic floor reconstruction with biological mesh following ELAPER without the additional use of myocutaneous flaps. The low serious complication rate, good outcomes in perineal wound healing and the absence of perineal hernias demonstrates that this is a safe and feasible procedure.

Prognostic factors associated with locally recurrent rectal cancer following primary surgery (Review)

Locally recurrent rectal cancer (LRRC) is defined as an intrapelvic recurrence following a primary rectal cancer resection, with or without distal metastasis. The treatment of LRRC remains a clinical challenge. LRRC has been regarded as an incurable disease state leading to a poor quality of life and a limited survival time. However, curative reoperations have proved beneficial for treating LRRC. A complete resection of recurrent tumors (R0 resection) allows the treatment to be curative rather than palliative, which is a milestone in medicine. In LRRC cases, the difficulty of achieving an R0 resection is associated with the post-operative prognosis and is affected by several clinical factors, including the staging of the local recurrence (LR), accompanying symptoms, patterns of tumors and combined therapy. The risk factors following primary surgery that lead to an increased rate of LR are summarized in this study, including the surgical, pathological and therapeutic factors.

Local recurrence after prone vs supine abdominoperineal excision for low rectal cancer

AIM

Tumour-involved circumferential resection margins (CRMs) and intra-operative perforation (IOP) are well known risk factors for local recurrence after surgery for low rectal cancer. In conventional abdominoperineal excision (APE) the patient remains in the supine position for the perineal part of the procedure. However, turning the patient to the prone position may improve visualization which potentially might reduce the risk of involved CRMs and IOP and thus improve local control. The study was carried out to assess local recurrence rates after APE in relation to the positioning of the patient during the perineal part of the procedure.

METHOD

This cohort study includes 466 patients having APE for low rectal cancer between 2001 and December 2010. Data were retrieved from the regional rectal cancer registry in Stockholm and from a retrospective review of patient files.

RESULTS

An incomplete resection was reported in 12.4% after APE in the supine position and in 6.8% after APE in the prone position (P = 0.038). Corresponding figures for IOP were 12.4% and 4.0% (P < 0.001). Prone APE was associated with a 39% relative reduction in local recurrence events compared with APE in the supine position, although the difference was not statistically significant (hazard ratio 0.61, 95% CI 0.27-1.37).

CONCLUSION

APE in the prone position reduced the incidence of incomplete resection and IOP, but the study did not find a statistically significant difference in local failure rates related to the position of the patient.

A novel approach for the resection of low rectal cancer

BACKGROUND

Our novel approach is a hybrid between cylindrical abdominoperineal resection and single-incision laparoscopic surgery (SILS). We report the clinical application of this technique and present preliminary data that shows this approach to be an effective tool for resection of low rectal cancer.

METHODS

Twenty patients with endoscopy-considered and biopsy-proven malignant lesions were required to undergo abdominal computed tomography examination for determining tumor stage. In addition, all patients had taken in digital rectal examination again on the surgery day. Perioperative management of patients was executed according to management of patients in fast-track surgery. First, cylindrical abdominoperineal resection was performed with the patients in the prone jackknife position to peritoneal reflection, then we turned the patients to the supine position and SILS was performed with the homemade single-port device.

RESULTS

The average distance from the anal verge was 2.60±1.14 cm and the mean tumor diameter confirmed by pathology measured to be 3.00±1.08 cm, and the circumferential margin was negative in all the specimens. The mean fabrication and set-up time of the homemade SILS device was 7.75±1.21 minutes and the average operating time was 138.55±9.32 minutes with minimal blood loss (20.5±5.83 mL). There were no conversions from SILS to conventional laparoscopy. On average, oral intake can often be successfully initiated 7.35±1.35 h after surgery, with the first passage of flatus from the colostomy occurring 2.55±0.76 d postoperation. Function hospital stay was 4.25±0.97 d with no undue sequelae. During the 6-month-long follow-up stage, no morbidity or mortality was observed except in 2 patients with poor union in perineum incision.

CONCLUSIONS

Cylindrical abdominoperineal decection combined with SILS is a feasible alternative for low rectal cancer, providing benefits like leaving enough exposure for operation, reducing trauma to surrounding organs, almost completely avoiding circumferential involvement, and allowing fast postoperative recovery.