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van Kessel CS, Waller J, Steffens D, Lee PJ, Austin KKS, Stalley PD, Solomon MJ. Improving Surgical Outcomes in Pelvic Exenteration Surgery: Comparison of Prone Sacrectomy With Anterior Cortical Sacrectomy Techniques. Ann Surg 2023; 278:945-953. [PMID: 37485983 DOI: 10.1097/sla.0000000000006040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes. BACKGROUND In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes. METHODS A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed. RESULTS A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time ( P <0.01) and more blood loss ( P <0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections ( P <0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) ( P =0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively ( P =0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS. CONCLUSIONS Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.
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Affiliation(s)
- Charlotte S van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jacob Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter J Lee
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul D Stalley
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Jones A, Findlay A, Knight SR, Rees J, O'Reilly D, Jones RP, Pathak S. Follow up after surgery for colorectal liver metastases: A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107103. [PMID: 37890234 DOI: 10.1016/j.ejso.2023.107103] [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: 04/21/2023] [Revised: 09/04/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Recurrence post hepatectomy for colorectal liver metastases (CRLM) occurs in 70 % of patients within two years. No established guidance on the method or intensity of follow-up currently exists. The aim of this systematic review was to summarise literature and determine whether it is possible to identify an optimal follow up regime. To this date there are no randomised prospective studies investigating this. METHODS A systematic review was performed according to PRISMA guidelines. Outcomes included general demographics, method, frequency and duration of follow up, survival and recurrence data. Quality assessment of the papers was performed. RESULTS Twenty-five articles published between 1994 and 2022 were included, including 9945 patients. CT was the most common imaging modality (n = 14) and CEA most common blood test (n = 11). Intensity of follow up was higher in the first two years post resection and only two papers continued follow up post 5 years resection. There was wide variation in outcome measures - Overall survival (OS) was most commonly reported. Nine papers reported OS ranging between 39 and 78.1 %. CONCLUSIONS There is wide variation in follow up methods and outcome reporting. There is no strong evidence to support intensive follow up, and the benefits of long term follow up are also unknown due to the lack of patient centred data. High quality, prospective studies should be the focus of future research as further retrospective data is unlikely to resolve uncertainties around optimal follow up.
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Affiliation(s)
- Annabel Jones
- University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough St, Bristol, BS1 3NU, UK
| | - Alasdair Findlay
- Department of Abdominal Medicine and Surgery, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Stephen R Knight
- Centre for Medical Informatics, Usher Institute, Nine Edinburgh BioQuarter, 9 Little France Road, EH16 4UX, UK
| | - Jonathan Rees
- University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough St, Bristol, BS1 3NU, UK
| | - David O'Reilly
- Cardiff Liver Unit, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Robert P Jones
- Institute of Translational Medicine, University of Liverpool, Brownlow Hill, Liverpool, L69 3BX, UK
| | - Samir Pathak
- Department of Abdominal Medicine and Surgery, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
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Risk factors for postoperative urinary retention in patients undergoing colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2409-2420. [PMID: 36357736 DOI: 10.1007/s00384-022-04281-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Postoperative urinary retention (POUR) is a common complication following colorectal surgery. The incidence of POUR among colorectal surgery patients varies widely, and the risk factors and outcomes of POUR are also debatable. This meta-analysis aims to systematically evaluate the risk factors for POUR in patients after colorectal surgery. METHODS PubMed, Web of Science, the Cochrane Library, Embase, Medline, and Chinese databases (CBM, CNKI, and WanFang Databases) were searched to identify relevant cohort studies (from inception to August 2022). Two researchers independently conducted literature quality evaluation and data extraction. All data were analyzed by using the Review Manager 5.4 software. RESULTS Nineteen studies with 101,025 patients were included in this meta-analysis. The risk factors for POUR in colorectal surgery patients were male sex, older age, diabetes mellitus, urological diseases, tumor location in the lower rectum, APR, laparoscopic surgery, operation time ≥ 4 h, postoperative date of urinary catheter removal, excessive intraoperative intravenous fluid volume, and postoperative ileus. The postoperative anastomotic leak, on the other hand, was not a risk factor for POUR. CONCLUSIONS Multiple risk factors influence the incidence of POUR in patients undergoing colorectal surgery. To reduce the incidence of POUR in colorectal surgery patients, medical staff should identify risk factors early and enforce interventions to prevent them.
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Fahy MR, Hayes C, Kelly ME, Winter DC. Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2284-2291. [PMID: 35031157 DOI: 10.1016/j.ejso.2021.12.471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/23/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. BACKGROUND The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures. METHODS A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582). RESULTS 14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%. LIMITATIONS The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies. CONCLUSIONS Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.
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Affiliation(s)
- Matthew R Fahy
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland.
| | - Cathal Hayes
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Michael E Kelly
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Desmond C Winter
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
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Kitakaze M, Uemura M, Kobayashi Y, Paku M, Miyo M, Takahashi Y, Miyake M, Kato T, Ikeda M, Fujino S, Ogino T, Miyoshi N, Takahashi H, Yamamoto H, Mizushima T, Sekimoto M, Doki Y, Eguchi H. Postoperative pain management after concomitant sacrectomy for locally recurrent rectal cancer. Surg Today 2022; 52:1599-1606. [PMID: 35661260 DOI: 10.1007/s00595-022-02522-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain. METHODS Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra. RESULTS Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05). CONCLUSIONS Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence.
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Affiliation(s)
- Masatoshi Kitakaze
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan.
| | - Yuta Kobayashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masakatsu Paku
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masaaki Miyo
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Yusuke Takahashi
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Takeshi Kato
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masataka Ikeda
- Division of Lower GI Surgery, Department of Surgery, Hyogo College of Medicine, Hyogo, 6638501, Japan
| | - Shiki Fujino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Osaka, 5731010, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
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Rogers AC, Jenkins JT, Rasheed S, Malietzis G, Burns EM, Kontovounisios C, Tekkis PP. Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer. J Clin Med 2021; 10:jcm10214921. [PMID: 34768442 PMCID: PMC8584798 DOI: 10.3390/jcm10214921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.
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Affiliation(s)
- Ailín C. Rogers
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - John T. Jenkins
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Shahnawaz Rasheed
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
| | - George Malietzis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
| | - Elaine M. Burns
- Department of Surgery, St. Mark’s Hospital, Watford Road, Harrow HA1 3UJ, UK; (J.T.J.); (E.M.B.)
| | - Christos Kontovounisios
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
- Correspondence:
| | - Paris P. Tekkis
- Department of Surgery, Royal Marsden Hospital, London SW3 6JJ, UK; (A.C.R.); (S.R.); (G.M.); (P.P.T.)
- Colorectal Surgical Unit, Chelsea and Westminster Hospital, Chelsea, London SW10 9NH, UK
- Department of Surgery and Cancer, The Royal Marsden Campus, Chelsea and Westminster Hospital and Imperial College, Paddington, London SW10 9NH, UK
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Matsui H, Ichikawa N, Homma S, Yoshida T, Emoto S, Imaizumi K, Miyaoka Y, Taketomi A. Combined Laparoscopic and Transperineal Endoscopic Pelvic Tumor Resection with Sacrectomy for Locally Recurrent Rectal Cancer. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:327-333. [PMID: 34395947 PMCID: PMC8321584 DOI: 10.23922/jarc.2020-050] [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: 12/25/2020] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
Pelvic tumor resection with sacrectomy for locally recurrent rectal cancer is a challenging operation with a high complication rate and poor prognosis. We report a case of pelvic tumor resection with sacrectomy by transperineal endoscopy following laparoscopic dissection for locally recurrent rectal cancer. A 70-year-old man underwent laparoscopic abdominoperineal resection for rectal cancer and was diagnosed with local pelvic recurrence on follow-up computed tomography (CT) three years postoperatively. As the recurrence was in contact with the front of the sacrum, we concluded that distal sacrectomy was necessary to ensure a surgical margin. We safely performed combined laparoscopic and transperineal endoscopic pelvic tumor resection with sacrectomy by exposing the surface of the sacrum from both abdominal and transperineal approach. The operative time was 200 minutes, with minimal blood loss. There was no tumor exposure on the surgically dissected surface, and the patient was discharged without complications 14 days postoperatively. Transperineal endoscopy may be useful for pelvic tumor resection with sacrectomy for locally recurrent rectal cancer.
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Affiliation(s)
- Hiroki Matsui
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shin Emoto
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ken Imaizumi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoichi Miyaoka
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Hondo N, Miyagawa Y, Kitazawa M, Muranaka F, Tokumaru S, Koyama M, Takahata S, Soejima Y. Laparoscopic abdominosacral resection for rectal and anal canal carcinoma with pagetoid spread. Asian J Endosc Surg 2021; 14:624-627. [PMID: 32875728 DOI: 10.1111/ases.12856] [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] [Received: 04/07/2020] [Revised: 07/09/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Perianal Paget's disease is associated with adenocarcinoma and can spread to the perianal skin. It often requires extensive resection of the perianal skin and rectum. Many studies have shown the efficacy of laparoscopic abdominoperineal resection for lower rectal cancer. However, extensive resection of the dorsal side of the perineal skin is difficult in the lithotomy position. We report a laparoscopic abdominosacral approach using the jackknife position for perianal Paget's disease. MATERIALS AND SURGICAL TECHNIQUE Surgery was started using the lithotomy position, and total mesorectal excision with central lymphadenectomy was performed laparoscopically. Pelvic floor muscles were divided 2 cm away from the rectum. The sigmoid colon was then divided with a linear stapler, and a terminal colostomy was made. The sacral approach was then followed with the patient placed in a jackknife position. A skin incision was made 1-2 cm from the negative margin confirmed by preoperative mapping biopsy and resected en-bloc. We used this approach in two patients with a mean operative time of 483 minutes, including 53.5 minutes for the position change. All tumor margins, including the skin, were cancer-free, and primary wound closure was possible in both of the cases. Both patients were doing well without any recurrence 10 and 13 months postoperatively. CONCLUSION Laparoscopic abdominosacral resection is safe and effective and facilitates extensive perineal skin resection, especially on the dorsal side, with a less invasive laparoscopic procedure.
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Affiliation(s)
- Nao Hondo
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yusuke Miyagawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masato Kitazawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Futoshi Muranaka
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shigeo Tokumaru
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Koyama
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shugo Takahata
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Gao Z, Gu J. Surgical treatment of locally recurrent rectal cancer: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1026. [PMID: 34277826 PMCID: PMC8267292 DOI: 10.21037/atm-21-2298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
Objective To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC). Background LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life. Methods We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020. Conclusions LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.
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Affiliation(s)
- Zhaoya Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China.,Department of Gastrointestinal Surgery III, Peking University Cancer Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
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10
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Tuech JJ, Pinson J, Nouhaud FX, Wood G, Clavier T, Sabourin JC, Di Fiore F, Monge M, Papet E, Coget J. Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety. Cancers (Basel) 2020; 12:cancers12113478. [PMID: 33238384 PMCID: PMC7700214 DOI: 10.3390/cancers12113478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment for patients with peritoneal carcinomatosis. Pelvic exenteration is an established treatment option for locally advanced pelvic malignancy. Based on the argument that high-risk complications arise from each procedure, the majority of researchers do not recommend performing a CRS/HIPEC with pelvis exenteration. Herein, we critically analyzed the data from 16 patients treated by these two procedures for 15 rectal and one appendiceal adenocarcinomas. Clear resection (R0) margins were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications that led to death in two cases (12.5%). Survival rates were not clarified, since the follow-up is ongoing. Pelvis exenteration associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC if a R0 resection could be achieved. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended. Abstract Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases. Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality. Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4–16). Mean duration of the surgical procedure was 596 min (420–840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage. Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.
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Affiliation(s)
- Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
- Correspondence: ; Tel.: +33-232-888-142; Fax: +33-232-8884
| | - Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | | | - Gregory Wood
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (G.W.); (T.C.)
| | - Thomas Clavier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (G.W.); (T.C.)
| | - Jean-Christophe Sabourin
- Department of Pathology, Iron Group, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France;
| | - Frederic Di Fiore
- Department of Digestive Oncology, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France;
| | - Matthieu Monge
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | - Eloïse Papet
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | - Julien Coget
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
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Lau YC, Jongerius K, Wakeman C, Heriot AG, Solomon MJ, Sagar PM, Tekkis PP, Frizelle FA. Influence of the level of sacrectomy on survival in patients with locally advanced and recurrent rectal cancer. Br J Surg 2019; 106:484-490. [PMID: 30648734 DOI: 10.1002/bjs.11048] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/25/2018] [Accepted: 10/10/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Exenterative surgery for locally advanced rectal cancer may involve partial sacrectomy to achieve complete resection. High sacrectomy is technically challenging, and can be associated with high morbidity and mortality rates. The aim of this study was to determine the influence of the level of sacrectomy on the survival of patients with locally advanced rectal cancer. METHODS This was an international multicentre retrospective analysis of patients undergoing exenterative abdominosacrectomy between July 2006 and June 2016. High sacrectomy was defined as resection at or above the junction of S2-S3; low sacrectomy was below the S2-S3 junction. Kaplan-Meier survival analysis was used to assess overall survival and cancer-specific survival. Predictive factors were determined using Cox regression analysis. RESULTS A total of 345 patients were identified, of whom 91 underwent high sacrectomy and 254 low sacrectomy. There was no difference in 5-year overall survival (53 versus 44·1 per cent; P = 0·216) or cancer-specific survival (60 versus 56·1 per cent; P = 0·526) between high and low sacrectomy. Negative margin rates were similar for primary and recurrent disease: 65 of 90 (72 per cent) versus 97 of 153 (63·4 per cent) (P = 0·143). Level of sacrectomy was not a significant predictor of mortality (P = 0·053). Positive resection margin and advancing age were the only significant predictors for death, with hazard ratios of 2·78 (P < 0·001) and 1·02 (P = 0·020) respectively. CONCLUSION There was no survival difference between patients who underwent high or low sacrectomy. In appropriately selected patients, high sacrectomy is feasible and safe.
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Affiliation(s)
- Y C Lau
- Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K Jongerius
- Department of General Surgery, University of Otago, Christchurch, New Zealand
| | - C Wakeman
- Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand.,Department of General Surgery, University of Otago, Christchurch, New Zealand
| | - A G Heriot
- Department of Colorectal Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P M Sagar
- Department of Colorectal Surgery, Leeds General Infirmary, Leeds, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - F A Frizelle
- Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand.,Department of General Surgery, University of Otago, Christchurch, New Zealand
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S1 Sacrectomy for Re-recurrent Rectal Cancer: Our Experience with Reconstruction Using an Expandable Vertebral Body Replacement Device. Dis Colon Rectum 2018; 61:261-265. [PMID: 29337783 DOI: 10.1097/dcr.0000000000000935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION R0 resection is achieved by high sacrectomy for local recurrence of colorectal cancer, but significant rates of perioperative complications and long-term patient morbidity are associated with this procedure. In this report, we outline our unique experience of using an expandable cage for vertebral body reconstruction following S1 sacrectomy in a 66-year-old patient with re-recurrent rectal cancer. We aim to highlight several key steps, with a view to improving postoperative outcomes. TECHNIQUE A midline laparotomy was performed with the patient in supine Lloyd-Davies position, demonstrating recurrence of tumor at the S1 vertebral body. Subtotal vertebral body excision of S1 with sparing of the posterior wall and ventral foramina was completed by using an ultrasonic bone aspirator. Reconstruction was performed using an expandable corpectomy spacer system. The system was assembled and expanded in situ to optimally bridge the corpectomy. The device was secured into the L5 and S2 vertebrae by means of angled end plate screws superiorly and inferiorly. Bone grafts were positioned adjacent to the implant after this. RESULTS Total operating time was 266 minutes with 350 mL of intraoperative blood loss. There were no immediate postoperative complications. The patient did not report any back pain at the time of discharge, and no neurological deficit was reported or identified. Postoperative CT scan showed excellent vertebral alignment and preservation of S1 height. CONCLUSION We conclude that high sacrectomy with an expandable metal cage is feasible in the context of re-recurrent rectal cancer when consideration is given to the method of osteotomy and vertebral body replacement.
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Pelvic Exenteration Surgery: The Evolution of Radical Surgical Techniques for Advanced and Recurrent Pelvic Malignancy. Dis Colon Rectum 2017; 60:745-754. [PMID: 28594725 DOI: 10.1097/dcr.0000000000000839] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.
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The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer. Ann Surg 2017; 264:323-9. [PMID: 26692078 DOI: 10.1097/sla.0000000000001524] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer. BACKGROUND Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control. METHODS Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease. RESULTS Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes. CONCLUSIONS R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.
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Systematic Review of Pelvic Exenteration With En Bloc Sacrectomy for Recurrent Rectal Adenocarcinoma: R0 Resection Predicts Disease-free Survival. Dis Colon Rectum 2017; 60:346-352. [PMID: 28177998 DOI: 10.1097/dcr.0000000000000737] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure. OBJECTIVE The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer. DATA SOURCES A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations. STUDY SELECTION Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma. MAIN OUTCOME MEASURE Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured. RESULTS A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection. LIMITATION The studies assessed by this review were retrospective case series and thus are subject to significant bias. CONCLUSION Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.
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Tsarkov PV, Efetov SK, Sidorova LV, Tulina IA. [Sacral resection in surgical treatment of locally advanced primary and recurrent rectal and anal cancer: short-term outcomes]. Khirurgiia (Mosk) 2017:4-13. [PMID: 28745699 DOI: 10.17116/hirurgia201774-13] [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] [Indexed: 06/07/2023]
Abstract
AIM To assess safety of rectum removal with distal sacral resection. MATERIAL AND METHODS The short-term results of surgical treatment of primary and recurrent locally advanced rectal and anal cancer with sacral fixation have been analyzed. 32 patients underwent combined operations with sacral resection at the level of S2-S5. In 12 patients only one point of tumor fixation (F1) was revealed, 10 patients had two points of fixation (F2), three patients had three fixation points (F3) and in 7 cases the tumor was fixed to four points (F4) of fixation to different pelvic structures. RESULTS AND DISCUSSION Mean intraoperative blood loss and surgery time was 551±81 ml and 320±20 min in cases of sacral fixation only that was significantly lower compared with F2 cases - 1278±551 ml and 433±45 min, F3 cases - 2200±600 ml and 620±88 min, F4 cases - 2157±512.5 ml and 519±52,3 min, respectively (р<0.05). Complications requiring surgical intervention occurred in 9% patients (n=3). Among 23 patients with intact bladder and ureters urinary disorders occurred in 42% (n=10). Resection margin was negative along posterior surface of the specimen in all cases. CONCLUSION Advanced surgery with distal sacral resection is advisable for radical removal of locally advanced and recurrent rectal and anal canal cancer fixed to the sacrum with negative resection margin. These operations are feasible in specialized centers and should be performed by specially trained oncological or colorectal surgeon.
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Affiliation(s)
- P V Tsarkov
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| | - S K Efetov
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| | - L V Sidorova
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| | - I A Tulina
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
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Belli F, Gronchi A, Corbellini C, Milione M, Leo E. Abdominosacral resection for locally recurring rectal cancer. World J Gastrointest Surg 2016; 8:770-778. [PMID: 28070232 PMCID: PMC5183920 DOI: 10.4240/wjgs.v8.i12.770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/14/2016] [Accepted: 10/24/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma.
METHODS A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.
RESULTS At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.
CONCLUSION Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.
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Helewa RM, Park J. Surgery for Locally Advanced T4 Rectal Cancer: Strategies and Techniques. Clin Colon Rectal Surg 2016; 29:106-13. [PMID: 27247535 PMCID: PMC4882171 DOI: 10.1055/s-0036-1580722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Locally advanced T4 rectal cancer represents a complex clinical condition that requires a well thought-out treatment plan and expertise from multiple specialists. Paramount in the management of patients with locally advanced rectal cancer are accurate preoperative staging, appropriate application of neoadjuvant and adjuvant treatments, and, above all, the provision of high-quality, complete surgical resection in potentially curable cases. Despite the advanced nature of this disease, extended and multivisceral resections with clear margins have been shown to result in good oncological outcomes and offer patients a real chance of cure. In this article, we describe the assessment, classification, and multimodality treatment of primary locally advanced T4 rectal cancer, with a focus on surgical planning, approaches, and outcomes.
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Affiliation(s)
- Ramzi M. Helewa
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jason Park
- Section of Surgical Oncology, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Xynos E, Tekkis P, Gouvas N, Vini L, Chrysou E, Tzardi M, Vassiliou V, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Dervenis C, Emmanouilidis C, Georgiou P, Katopodi O, Kountourakis P, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Triantopoulou C, Xynogalos S, Karachaliou N, Ziras N, Zoras O, Souglakos J. Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:103-26. [PMID: 27064746 PMCID: PMC4805730 DOI: 10.20524/aog.2016.0003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.
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Affiliation(s)
- Evaghelos Xynos
- General Surgery, InterClinic Hospital of Heraklion, Greece (Evangelos Xynos)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Nikolaos Gouvas
- General Surgery, Metropolitan Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Louiza Vini
- Radiation Oncology, Iatriko Center of Athens, Greece (Louza Vini)
| | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Ioannis Boukovinas
- Medical Oncology, Bioclinic of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, Venizeleion Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Christos Dervenis
- General Surgery, Konstantopouleio Hospital of Athens, Greece (Christos Dervenis)
| | - Christos Emmanouilidis
- Medical Oncology, Interbalkan Medical Center, Thessaloniki, Greece (Christos Emmanouilidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Ourania Katopodi
- Medical Oncology, Iaso General Hospital, Athens, Greece (Ourania Katopodi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, Ippokrateion Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, Theageneion Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, Agioi Anargyroi Hospital of Athens, Greece (Joseph Sgouros)
| | | | - Spyridon Xynogalos
- Medical Oncology, George Gennimatas General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institute, Barcelona, Spain (Niki Karachaliou)
| | - Nikolaos Ziras
- Medical Oncology, Metaxas Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - Odysseas Zoras
- General Surgery, University Hospital of Heraklion, Greece (Odysseas Zoras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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CT colonography for surveillance of patients with colorectal cancer: Systematic review and meta-analysis of diagnostic efficacy. Eur Radiol 2016; 27:51-60. [DOI: 10.1007/s00330-016-4319-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 01/12/2016] [Accepted: 03/02/2016] [Indexed: 12/11/2022]
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Belli A, Bianco F, De Franciscis S, Romano GM. Indications for Surgery and Surgical Techniques. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cuicchi D, Lecce F, Dalla Via B, De Raffele E, Mirarchi M, Cola B. Mortality and Morbidity. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Denost Q, Faucheron J, Lefevre J, Panis Y, Cotte E, Rouanet P, Jafari M, Capdepont M, Rullier E, Pezet, Tuech, Benchimol, Massard, Prudhomme, Gainant, Regimbeau, Chenet, Pautrat, Paineau, Peluchon, Elias, Dumont, Evrard, Beaulieu, Mabrut, Vaudois, Rio, Gouthi, Mauvais, Bresler, Boissel, Tiret, Parc, Glehen, Rohr, Sastre, Paineau, Chenet, Fancois, Singier, Voirin, Risse, Quenet, Joyeux, Saint-Aubert, Khalil. French current management and oncological results of locally recurrent rectal cancer. Eur J Surg Oncol 2015; 41:1645-52. [DOI: 10.1016/j.ejso.2015.09.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/26/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022] Open
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Troja A, El-Sourani N, Abdou A, Antolovic D, Raab HR. Surgical options for locally recurrent rectal cancer--review and update. Int J Colorectal Dis 2015; 30:1157-63. [PMID: 25989927 DOI: 10.1007/s00384-015-2249-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 02/07/2023]
Abstract
Locally recurrent rectal tumours in the pelvis are found in about 6% following treatment for rectal cancer. This type of tumour can cause serious local complications and symptoms. The aim of modern surgical oncology is to offer a curative treatment option embedded in an interdisciplinary network of specialities to the patient. Due to advancements in surgical techniques and procedures, especially regarding surgical reconstruction, the possibilities of a curative treatment regarding recurrent cancers have been expanded and established. To aim for a curative treatment one must introduce a multimodal therapy including radio- and chemotherapy, and a radical oncological surgery with en bloc resection of the tumour and affected surrounding organs to achieve a R0-resection.
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Affiliation(s)
- A Troja
- University Department of General and Visceral Surgery, European Medical School, Klinikum Oldenburg, Rahel-Strauss-Str.10, Oldenburg, 26133, Germany,
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Fazeli MS, Keramati MR. Rectal cancer: a review. Med J Islam Repub Iran 2015; 29:171. [PMID: 26034724 PMCID: PMC4431429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/24/2014] [Indexed: 11/22/2022] Open
Abstract
Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.
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Affiliation(s)
- Mohammad Sadegh Fazeli
- 1 Associate Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Reza Keramati
- 2 Assistant Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
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Georgiou PA, Bhangu A, Brown G, Rasheed S, Nicholls RJ, Tekkis PP. Learning curve for the management of recurrent and locally advanced primary rectal cancer: a single team's experience. Colorectal Dis 2015; 17:57-65. [PMID: 25204543 DOI: 10.1111/codi.12772] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 07/15/2014] [Indexed: 12/12/2022]
Abstract
AIM The study aimed to define the learning curve required to gain satisfactory training to perform pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer. METHOD Consecutive patients undergoing exenterative pelvic surgery for recurrent and locally advanced primary rectal cancer, by one surgical team, between 2006 and 2011 were studied. They were divided into quartiles (Q1-Q4) according to the date of surgery. A risk-adjusted cumulative sum (RA-CUSUM) model was used to evaluate the learning curve. The chi-squared test with gamma ordinal was used to assess the change with time in the four quartiles. RESULTS One hundred patients (70 males; median age 61 (25-85) years; 55 primary cancers) were included in the study. Thirty patients underwent abdominosacral resection. The number of patients who underwent plastic reconstruction (n = 53) increased from 12 in Q1 to 15 in Q4 (P = 0.781). The median operation time, intra-operative blood loss and hospital stay were 8 (3-17) h, 1.5 (0.1-17) l and 15 (9-82) days respectively. There was no significant change with time. Complete resection (R0) was achieved in 78 patients. Microscopic (R1) or macroscopic (R2) residual disease was present in 15 and seven patients respectively. The number of major complications was 20, and minor 30. RA-CUSUM analysis demonstrated an improvement in any complications after 14, in major after 12 and in minor after 25 operations. CONCLUSION Pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer is complex and requires a minimum of 14 cases for an expert colorectal surgeon to gain the desirable training and experience to improve morbidity.
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Affiliation(s)
- P A Georgiou
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, Chelsea and Westminster Campus, London, UK
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Uehara K, Ito Z, Yoshino Y, Arimoto A, Kato T, Nakamura H, Imagama S, Nishida Y, Nagino M. Aggressive surgical treatment with bony pelvic resection for locally recurrent rectal cancer. Eur J Surg Oncol 2014; 41:413-20. [PMID: 25477268 DOI: 10.1016/j.ejso.2014.11.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 10/13/2014] [Accepted: 11/06/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In the current era of total mesorectal excision, local relapse remains a main cause of recurrence. Although standard treatment for locally recurrent rectal cancer (LRRC) has not been established, R0 resection represents the only potentially curative treatment. However, extended surgery accompanying bony pelvic resection is technically demanding and is still challenging. METHODS Studied were 35 patients with LRRC who underwent combined resection of bony pelvis between August 2006 and October 2013. Safety and prognostic factors for survival were analyzed. Median follow-up was 33 months. RESULTS Sacrectomy was performed in 32 patients and 3 patients underwent combined resection of the pubis and ischium. The dominant operative procedure was total pelvic exenteration in 30 (86%) patients. R0 resection was achieved in 27 (77%) patients. No patients died. Pelvic sepsis was the most frequent complication (40%). Recurrence developed in 20 (57%), with the lung the most frequent site (10 patients). Three-year local relapse-free survival (LRFS) and disease-free survival (DFS) were 72.1% and 32.7%, respectively. On multivariate analysis, R1 resection was the only independent risk factor for local recurrence (p = 0.010), and concomitant liver metastasis and initial non sphincter-preserving surgery were independent predictors of worse DFS (p = 0.008 and p = 0.042, respectively). CONCLUSIONS Aggressive surgical treatment combined with bony resection for carefully selected patients with LRRC was safe with a high rate of R0 resection and favorable LRFS. However, DFS was not satisfactory even after R0 resection and the main cause was lung metastasis. Preventing distant recurrence might be a key to improve survival.
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Affiliation(s)
- K Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Z Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Yoshino
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - A Arimoto
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - T Kato
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - H Nakamura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - S Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Nishida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Bhangu A, Rasheed S, Brown G, Tait D, Cunningham D, Tekkis P. Does rectal cancer height influence the oncological outcome? Colorectal Dis 2014; 16:801-8. [PMID: 24980955 DOI: 10.1111/codi.12703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/16/2014] [Indexed: 02/08/2023]
Abstract
AIM The influence of the height of rectal cancer from the anal verge on the oncological outcome is controversial. This study aimed to determine the influence of the height of the tumour on the survival of patients treated in a specialized rectal cancer unit. METHOD Patients undergoing surgery for primary rectal cancer from 2006 to 2013 were identified from a prospectively maintained rectal cancer database. Those requiring total or multicompartmental pelvic exenteration were excluded. Low cancer was defined as tumour < 5 cm from the anal verge, as assessed by endoscopy and/or digital rectal examination. The primary outcome was 3-year disease-free survival (DFS). RESULTS Of 340 patients, 203 (59.7%) had low cancer. There were 302 (89%) restorative and 38 (11%) nonrestorative procedures. The rate of positive circumferential resection margin was similar for low compared with high cancer (3.4% vs 2.9%, P = 1.0) and for restorative compared with nonrestorative procedures in low cancer only (3.0% and 5.3%, P = 0.619). Low compared with high anterior resection was associated with increased anastomotic leakage (8.5% vs 2.2%, P = 0.023). Three-year DFS was similar for low and high resection (82% vs 86%, P = 0.305) and between restorative vs nonrestorative procedures in low cancer only (88% vs 77%, P = 0.215). In an adjusted model, low height did not lead to worse survival outcome (3-year DFS hazard ratio 0.54, 95% CI 0.24-1.24, P = 0.147). CONCLUSION With careful planning and a multidisciplinary approach, equivalent oncological outcome can be achieved for patients with rectal cancer who undergo curative surgery regardless of differences in tumour characteristics, location and operation performed.
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Affiliation(s)
- A Bhangu
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK; Division of Surgery, Imperial College London, Chelsea and Westminster Campus, London, UK
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Thaysen HV, Jess P, Rasmussen PC, Nielsen MB, Laurberg S. Health-related quality of life after surgery for advanced and recurrent rectal cancer: a nationwide prospective study. Colorectal Dis 2014; 16:O223-33. [PMID: 24373460 DOI: 10.1111/codi.12551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 12/07/2013] [Indexed: 12/12/2022]
Abstract
AIM Advances in the treatment of rectal cancer have made it possible to perform complex rectal cancer surgery (COMP-RCS) in patients with primary advanced rectal cancer penetrating beyond the total mesorectal excision planes and in patients with locally recurrent rectal cancer. The aim of this study was to examine health-related quality of life (HRQoL) before and during the first 2 years after COMP-RCS. METHOD Between 2001 and 2008, 180 patients were treated with COMP-RCS at Aarhus University Hospital. HRQoL was assessed preoperatively and 3, 6, 12, 18 and 24 months after surgery using three questionnaires. The results were compared with those for patients treated with standard rectal cancer surgery (STAN-RCS) and with data from the general Danish population (NORM-data). RESULTS One hundred and twenty-two (68%) patients responded to the questionnaires. Of these 80 (66%) with disease-free survival for 2 years after surgery were included in the main analysis. The lowest level of functioning and the highest degree of symptoms were reported preoperatively. The majority of the HRQoL scales improved or remained stable during the first postoperative year; a decrease was observed for body image only. One year after surgery, HRQoL in patients treated with COMP-RSC was comparable to that for patients treated with STAN-RCS. Lower levels were found for physical and emotional role functioning, compared with NORM-data. CONCLUSION Patients treated with COMP-RCS experienced improvement in HRQoL in the first year after surgery. One year after surgery, HRQoL was similar to that of patients treated with STAN-RCS. Compared with NORM-data, lower levels were found for physical and emotional role functioning.
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Affiliation(s)
- H V Thaysen
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation. Tech Coloproctol 2014; 18:887-93. [PMID: 24890577 DOI: 10.1007/s10151-014-1150-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 04/12/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study aimed to prospectively quantify the frequency of serious bleeding during pelvic surgery for locally advanced or recurrent rectal cancer and review the surgical methods used to control this. METHODS Consecutive cases of pelvic surgery for curative resection of locally advanced or recurrent rectal cancer were prospectively evaluated over a nine-month period. The procedures undertaken included multivisceral resections, sacrectomies or ultra-low anterior resections. Multivisceral resections were defined as pelvic exenterations, extra-levator abdominoperineal resections (ELAPER) and recurrent anterior resections. The primary endpoint was the proportion of patients sustaining major blood loss, defined as ≥1,000 ml. The secondary endpoint was the blood transfusion rate. Haemostatic adjunct use was recorded. RESULTS Twenty-six patients underwent surgery, comprising 11 pelvic exenterations, 3 ELAPERs, 1 recurrent anterior resection, 5 abdominosacral resections and 6 ultra-low anterior resections. The median intraoperative blood loss was 1,250 ml with 53.8 % of the patients sustaining a loss ≥1,000 ml. Fifty per cent of patients required a blood transfusion within 24 h, and one or more haemostatic adjuncts were necessary in 50 % of the cases. Adjuncts used included a fibrinogen/thrombin haemostatic agent in 38.5 % of patients, temporary intraoperative pelvic packing in 11.5 % of patients and preoperative internal iliac artery embolization in 7.7 % of patients. CONCLUSIONS This patient group is at a high risk of intraoperative haemorrhage, and such patients are high consumers of blood products. Haemostatic adjunct use is often necessary to minimize blood loss. We describe our local algorithm to assist in the assessment and intraoperative management of these challenging cases.
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Bosman S, Vermeer T, Dudink R, de Hingh I, Nieuwenhuijzen G, Rutten H. Abdominosacral resection: Long-term outcome in 86 patients with locally advanced or locally recurrent rectal cancer. Eur J Surg Oncol 2014; 40:699-705. [DOI: 10.1016/j.ejso.2014.02.233] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/22/2014] [Accepted: 02/17/2014] [Indexed: 12/24/2022] Open
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Liao G, Zhao Z, Lin S, Li R, Yuan Y, Du S, Chen J, Deng H. Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trials. World J Surg Oncol 2014; 12:122. [PMID: 24767102 PMCID: PMC4002581 DOI: 10.1186/1477-7819-12-122] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Background Robotic-assisted laparoscopy is popularly performed for colorectal disease. The objective of this meta-analysis was to compare the safety and efficacy of robotic-assisted colorectal surgery (RCS) and laparoscopic colorectal surgery (LCS) for colorectal disease based on randomized controlled trial studies. Methods Literature searches of electronic databases (Pubmed, Web of Science, and Cochrane Library) were performed to identify randomized controlled trial studies that compared the clinical or oncologic outcomes of RCS and LCS. This meta-analysis was performed using the Review Manager (RevMan) software (version 5.2) that is provided by the Cochrane Collaboration. The data used were mean differences and odds ratios for continuous and dichotomous variables, respectively. Fixed-effects or random-effects models were adopted according to heterogeneity. Results Four randomized controlled trial studies were identified for this meta-analysis. In total, 110 patients underwent RCS, and 116 patients underwent LCS. The results revealed that estimated blood losses (EBLs), conversion rates and times to the recovery of bowel function were significantly reduced following RCS compared with LCS. There were no significant differences in complication rates, lengths of hospital stays, proximal margins, distal margins or harvested lymph nodes between the two techniques. Conclusions RCS is a promising technique and is a safe and effective alternative to LCS for colorectal surgery. The advantages of RCS include reduced EBLs, lower conversion rates and shorter times to the recovery of bowel function. Further studies are required to define the financial effects of RCS and the effects of RCS on long-term oncologic outcomes.
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Affiliation(s)
| | | | | | | | - Yawei Yuan
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, No, 1838, Guangzhou Avenue North, Guangzhou 510515, China.
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Mahadevan A. Intraoperative and stereotactic ablative radiation therapy in recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2013.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
STUDY DESIGN A review of prospectively collected data on a consecutive series of patients undergoing single-stage anterior high sacrectomy for locally recurrent rectal carcinoma (LRRC). OBJECTIVE To determine the clinical outcome of patients who underwent anterior high sacrectomy for LRRC. SUMMARY OF BACKGROUND DATA High sacrectomy for oncological resection remains technically challenging. Surgery has the potential to achieve cure in carefully selected patients. Complete (R0) tumor excision in LRRC may require sacrectomy. High sacral resections (S3 and above) typically require a combined anterior/supine and posterior/prone procedure. We investigated our experience performing single-stage anterior high sacrectomy for LRRC. METHODS A consecutive series of patients with LRRC without systemic metastases who underwent resection with curative intent requiring high sacrectomy were identified. A review of a prospectively maintained colorectal and spine cancer database data was performed. An oblique dome high sacral osteotomy was performed during a single-stage anterior procedure. Outcome measures included surgical resection margin status, hospital length of stay, postoperative complications, physical functioning status, and overall survival. RESULTS Nineteen consecutive patients were treated between 2002 and 2011. High sacrectomy was performed at sacral level S1-S2 in 4 patients, S2-S3 in 9 patients, and through S3 in 6 patients. An R0 resection margin was achieved histologically in all 19 cases. There was 1 early (<30 d) postoperative death (1/19, 5%). At median follow-up of 38 months, 13 patients had no evidence of residual disease, 1 was alive with disease, and 4 had died of disease. Morbidities occurred in 15 of the 19 patients (79%). CONCLUSION Although high sacrectomy may require a combined anterior and posterior surgical approach, our series demonstrates the feasibility of performing single-stage anterior high sacrectomy in LRRC, with acceptable risks and outcomes compared with the literature. The procedure described by us for LRRC lessens the need for a simultaneous or staged prone posterior resection, with favorable R0 tumor resections, patient survival, and clinical outcomes. LEVEL OF EVIDENCE N/A.
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Abstract
The management of rectal cancer has changed dramatically over the last few decades. Due to improvements in the multimodality treatment and the introduction of neoadjuvant chemoradiation, previously irresectable tumours can nowadays be cured by extensive multivisceral resections. These highly complex operations are associated with significant morbidity and mortality. Due to optimization of chemoradiotherapy, the introduction of IORT, increasing knowledge of tumour pathology and patterns of recurrence the need for extensive surgery diminishes. The question arises which patients with T4 rectal cancer really need extensive surgery and who can safely be considered for an organ preserving approach.
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Nagasaki T, Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Yamaguchi T. Laparoscopic abdominosacral resection for locally advanced primary rectal cancer after treatment with mFOLFOX6 plus bevacizumab, followed by preoperative chemoradiotherapy. Asian J Endosc Surg 2014; 7:52-5. [PMID: 24450344 DOI: 10.1111/ases.12068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/05/2013] [Accepted: 09/09/2013] [Indexed: 12/13/2022]
Abstract
Abdominosacral resection may be the only curative procedure for locally advanced rectal cancer involving the presacral fascia or sacrum. Multimodal therapy might be necessary to prevent local and distant recurrence for such tumors. A 67-year-old man was diagnosed with locally advanced rectal cancer widely involving the right pelvic sidewall and presacral fascia near the S4/5 junction on the right posterolateral side. We performed laparoscopic abdominosacral resection (S4/5) with en bloc right lateral lymph node dissection and seminal vesicle resection to obtain a clear resection margin after systemic chemotherapy with mFOLFOX6 (oxaliplatin, leucovorin, and 5-fluorouracil) plus bevacizumab, followed by preoperative chemoradiotherapy. The total operative time was 660 min, and the estimated blood loss was 550 mL. The final pathological findings revealed no residual cancer cells (pathological complete response). Laparoscopic abdominosacral resection appears to be safe and feasible in selected patients.
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Affiliation(s)
- Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Bhangu A, Fitzgerald JEF, Slesser A, Northover JM, Faiz O, Tekkis P. Prognostic significance of extramural vascular invasion in T4 rectal cancer. Colorectal Dis 2013; 15:e665-71. [PMID: 24103008 DOI: 10.1111/codi.12421] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 03/29/2013] [Indexed: 12/12/2022]
Abstract
AIM Extramural vascular invasion (EMVI) has been proposed as an adverse prognostic indicator in colorectal cancer, although its use remains both variable and controversial. This study aimed to determine the survival effect of EMVI in T4 rectal cancer. METHOD Patients undergoing surgery with curative intent for primary T4 rectal cancer between 1971 and 2011 were included from two prospectively collected rectal cancer databases. The main end-point was 3-year survival. RESULTS From 1142 patients undergoing resection of rectal cancer during the study period, 126 (11.0%) had T4 rectal cancer and were included in the study group. Sphincter preservation was performed in 61 (48%) and a pathologically negative resection margin (R0) was achieved in 104 patients (82.5%). EMVI was present in 51 patients (40.5%) and was an independent predictor of positive lymph node status (adjusted odds ratio 2.66, P = 0.013). Considering all patients, EMVI was associated with reduced overall survival (P = 0.007) and disease-free survival (P = 0.002), but not local recurrence-free survival (P = 0.198). In only those undergoing R0 resection, EMVI predicted reduced disease-free survival with positive nodal status (P = 0.021); it did not predict survival with negative nodal status. CONCLUSION Overall, EMVI was a strong prognostic marker of survival. However, after complete surgical resection in patients with node-negative disease, EMVI did not predict local recurrence.
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Affiliation(s)
- A Bhangu
- Department of Colorectal Surgery, the Royal Marsden Hospital, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK
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Yeo HL, Paty PB. Management of recurrent rectal cancer: Practical insights in planning and surgical intervention. J Surg Oncol 2013; 109:47-52. [DOI: 10.1002/jso.23457] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/10/2013] [Indexed: 01/28/2023]
Affiliation(s)
- Heather L. Yeo
- Department of Surgery; Memorial Sloan-Kettering Cancer Center; New York New York
| | - Philip B. Paty
- Department of Surgery; Memorial Sloan-Kettering Cancer Center; New York New York
- Department of Surgery; Cornell Weill Medical College; New York New York
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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100:1009-14. [PMID: 23754654 DOI: 10.1002/bjs.9192] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. METHODS Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. RESULTS The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. CONCLUSION The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.
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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100:E1-33. [PMID: 23901427 DOI: 10.1002/bjs.9192_1] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. METHODS Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. RESULTS The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. CONCLUSION The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.
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Lou Z, Zhang W, Meng RG, Fu CG. Massive presacral bleeding during rectal surgery: From anatomy to clinical practice. World J Gastroenterol 2013; 19:4039-4044. [PMID: 23840150 PMCID: PMC3703192 DOI: 10.3748/wjg.v19.i25.4039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 04/17/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate control of two different types of massive presacral bleeding according to the anatomy of the presacral venous system.
METHODS: A retrospective review was performed in 1628 patients with middle or low rectal carcinoma who were treated surgically in the Department of Colorectal Surgery, Changhai Hospital, Shanghai, China from January 2008 to December 2012. In four of these patients, the presacral venous plexus (n = 2) or basivertebral veins (n = 2) were injured with massive presacral bleeding during mobilization of the rectum. The first two patients with low rectal carcinoma were operated upon by a junior associate professor and the source of bleeding was the presacral venous plexus. The other two patients with recurrent rectal carcinoma were both women and the source of bleeding was the basivertebral veins.
RESULTS: Two different techniques were used to control the bleeding. In the first two patients with massive bleeding from the presacral venous plexus, we used suture ligation around the venous plexus in the area with intact presacral fascia that communicated with the site of bleeding (surrounding suture ligation). In the second two patients with massive bleeding from the basivertebral veins, the pelvis was packed with gauze, which resulted in recurrent bleeding as soon as it was removed. Following this, we used electrocautery applied through one epiploic appendix pressed with a long Kelly clamp over the bleeding sacral neural foramen where was felt like a pit Electrocautery adjusted to the highest setting was then applied to the clamp to “weld” closed the bleeding point. Postoperatively, the blood loss was minimal and the drain tube was removed on days 4-7.
CONCLUSION: Surrounding suture ligation and epiploic appendices welding are effective techniques for controlling massive presacral bleeding from presacral venous plexus and sacral neural foramen, respectively.
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Abstract
BACKGROUND Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer. OBJECTIVE This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration. DATA SOURCES A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified. STUDY SELECTION Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination. MAIN OUTCOME MEASURES Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates. RESULTS A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer. LIMITATIONS Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported. CONCLUSIONS Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.
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