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Galvez A, Biondo S, Trenti L, Espin E, Kraft M, Farres R, Codina-Cazador A, Flor B, Garcia-Granero E, Enriquez-Navascues JM, Borda-Arrizabalaga N, Kreisler E. Prognostic Value of the Circumferential Resection Margin After Curative Surgery for Rectal Cancer: A Multicenter Propensity Score-Matched Analysis. Dis Colon Rectum 2023; 66:887-897. [PMID: 35348529 DOI: 10.1097/dcr.0000000000002294] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recently, positive circumferential resection margin has been found to be an indicator of advanced disease with a high risk of distant recurrence rather than local recurrence. OBJECTIVE The study aimed to analyze the prognostic impact of the circumferential resection margin on long-term oncological outcomes in patients with rectal cancer. DESIGN This was a multicenter, propensity score-matched (2:1) analysis comparing the positive and negative circumferential resection margins. SETTINGS The study was conducted at 5 high-volume centers in Spain. PATIENTS Patients who underwent total mesorectal excision with curative intent for middle-low rectal cancer between 2006 and 2014 were included. MAIN OUTCOME MEASURES The main outcomes were local recurrence, distant recurrence, overall survival, and disease-free survival. RESULTS The unmatched initial cohort consisted of 1599 patients, of whom 4.9% had a positive circumferential resection margin. After matching, 234 patients were included (156 with a negative circumferential margin and 78 with a positive circumferential margin). The median follow-up period was 52.5 (22.0-69.5) months. Local recurrence was significantly higher in patients with a positive circumferential margin (33.3% vs 11.5%; p < 0.001). Distant recurrence was similar in both groups (46.2% vs 42.3%; p = 0.651). There were no statistically significant differences in 5-year overall survival (48.6% vs 43.6%; p = 0.14). Disease-free survival was lower in patients with a positive circumferential margin (36.1% vs 52.3%; p = 0.026). LIMITATIONS This study was limited by its retrospective design. The different neoadjuvant treatment options were not included in the propensity score. CONCLUSIONS The positive circumferential resection margin was associated with a higher local recurrence rate and worse disease-free survival in comparison with the negative circumferential resection margin. However, the positive circumferential resection margin was not a prognostic indicator of distant recurrence and overall survival. See Video Abstract at http://links.lww.com/DCR/B950 . VALOR PRONSTICO DEL MARGEN DE RESECCIN CIRCUNFERENCIAL DESPUS DE LA CIRUGA CURATIVA PARA EL CNCER DE RECTO UN ANLISIS MULTICNTRICO EMPAREJADO POR PUNTAJE DE PROPENSIN ANTECEDENTES:En los últimos años, se ha encontrado que el margen de resección circunferencial positivo es un indicador de enfermedad avanzada con alto riesgo de recurrencia a distancia más que de recurrencia local.OBJETIVO:El objetivo fue analizar el impacto pronóstico del margen de resección circunferencial sobre la recidiva local, a distancia y las tasas de supervivencia en pacientes con cáncer de recto.DISEÑO:Este fue un análisis multicéntrico emparejado por puntaje de propensión 2: 1 que comparó el margen de resección circunferencial positivo y negativo.AJUSTES:El estudio se realizó en 5 centros Españoles de alto volumen.PACIENTES:Se incluyeron pacientes sometidos a escisión total de mesorrecto con intención curativa por cáncer de recto medio-bajo entre 2006-2014. Las características clínicas e histológicas se utilizaron para el emparejamiento.PRINCIPALES MEDIDAS DE RESULTADO:Los resultadoes principales fueron la recurrencia local, la recurrencia a distancia, la supervivencia global y libre de enfermedad.RESULTADOS:La cohorte inicial no emparejada consistió en 1599 pacientes; El 4,9% tuvo un margen de resección circunferencial positivo. Tras el emparejamiento se incluyeron 234 pacientes (156 con margen circunferencial negativo y 78 con margen circunferencial positivo). La mediana del período de seguimiento fue de 52,5 meses (22,0-69,5). La recurrencia local fue significativamente mayor en pacientes con margen circunferencial positivo, 33,3% vs 11,5% [HR 3,2; IC 95%: 1,83-5,43; p < 0,001]. La recidiva a distancia fue similar en ambos grupos (46,2 % frente a 42,3 %) [HR 1,09, IC 95 %: 0,78-1,90; p = 0,651]. No hubo diferencias significativas en la supervivencia global a 5 años (48,6 % frente a 43,6 %) [HR 1,09, IC 95 %: 0,92-1,78; p = 0,14]; La supervivencia libre de enfermedad fue menor en pacientes con margen circunferencial positivo, 36,1% vs 52,3% [HR 1,5; IC 95%: 1,05-2,06; p = 0,026].LIMITACIONES:Este estudio estuvo limitado por el diseño retrospectivo. Las diferentes opciones de tratamientos neoadyuvantes no se han incluido en la puntuación de propensión.CONCLUSIONES:El margen de resección circunferencial positivo se asocia con una mayor tasa de recurrencia local y peor supervivencia libre de enfermedad en comparación con el margen de resección circunferencial negativo. Sin embargo, el margen de resección circunferencial positivo no fue un indicador pronóstico de recidiva a distancia ni de supervivencia global. Consulte el Video del Resumen en http://links.lww.com/DCR/B950 . (Traducción- Dr. Yesenia Rojas-Khalil ).
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Affiliation(s)
- Ana Galvez
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Sebastiano Biondo
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Loris Trenti
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - Eloy Espin
- Colorectal Unit, Department of General and Digestive Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Miquel Kraft
- Colorectal Unit, Department of General and Digestive Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ramón Farres
- Colorectal Unit, Department of General and Digestive Surgery, Josep Trueta University Hospital, Gsirona, Spain
| | - Antonio Codina-Cazador
- Colorectal Unit, Department of General and Digestive Surgery, Josep Trueta University Hospital, Gsirona, Spain
| | - Blas Flor
- Colorectal Unit, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - Eduardo Garcia-Granero
- Colorectal Unit, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - Jose M Enriquez-Navascues
- Colorectal Unit, Department of General and Digestive Surgery, Donostia University Hospital, San Sebastian, Spain
| | - Nerea Borda-Arrizabalaga
- Colorectal Unit, Department of General and Digestive Surgery, Donostia University Hospital, San Sebastian, Spain
| | - Esther Kreisler
- Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
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Zhang GQ, Sahyoun R, Stem M, Lo BD, Rajput A, Efron JE, Atallah C, Safar B. Operative Approach Does Not Impact Radial Margin Positivity in Distal Rectal Cancer. World J Surg 2021; 45:3686-3694. [PMID: 34495388 DOI: 10.1007/s00268-021-06278-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). METHODS This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. RESULTS Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). CONCLUSIONS No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.
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Affiliation(s)
- George Q Zhang
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Sahyoun
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian D Lo
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Reali C, Bocca G, Lindsey I, Jones O, Cunningham C, Guy R, George B, Boyce S. Influence of incorrect staging of colorectal carcinoma on oncological outcome: are we playing safely? Updates Surg 2021; 74:591-597. [PMID: 34231164 PMCID: PMC8995263 DOI: 10.1007/s13304-021-01095-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 10/25/2022]
Abstract
Accurate preoperative staging of colorectal cancers is critical in selecting patients for neoadjuvant therapy prior to resection. Inaccurate staging, particularly understaging, may lead to involved resection margins and poor oncological outcomes. Our aim is to determine preoperative imaging accuracy of colorectal cancers compared to histopathology and define the effect of inaccurate staging on patient selection for neoadjuvant treatment(NT). Staging and treatment were determined for patients undergoing colorectal resections for adenocarcinomas in a single tertiary centre(2016-2020). Data were obtained for 948 patients. The staging was correct for both T and N stage in 19.68% of colon cancer patients. T stage was under-staged in 18.58%. At resection, 23 patients (3.36%) had involved pathological margins; only 7 of which had been predicted by pre-operative staging. However, the staging was correct for both T and N stage in 53.85% of rectal cancer patients. T stage was understaged in 26.89%. Thirteen patients had involved(R1)margins; T4 had been accurately predicted in all of these cases. There was a general trend in understaging both the tumor and lymphonodal involvement (T p < 0.00001 N p < 0.00001) causing a failure in administrating NT in 0.1% of patients with colon tumor, but not with rectal cancer. Preoperative radiological staging tended to understage both colonic and rectal cancers. In colonic tumours this may lead to a misled opportunity to treat with neoadjuvant therapy, resulting in involved margins at resection.
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Affiliation(s)
- Claudia Reali
- Department of Colorectal Surgery, Colchester General Hospital, Turner Road, 33 Groves Close, Colchester, CO4 5JL, UK.
| | - Gabriele Bocca
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - Ian Lindsey
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - Oliver Jones
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - Chris Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - Bruce George
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - Stephen Boyce
- Department of Colorectal Surgery, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
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Delayed surgery after radio-chemotherapy for rectal adenocarcinoma is protective for anastomotic dehiscence: a single-center observational retrospective cohort study. Updates Surg 2020; 72:469-475. [PMID: 32306273 DOI: 10.1007/s13304-020-00770-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
Ideal time interval between end of neoadjuvant radio-chemotherapy (NRCT) and surgery for rectal cancer is debated. Effect that different time intervals have on postoperative complications with particular regard to anastomotic dehiscence (AD) was evaluated on 167 patients who underwent surgery after long-course NRCT. Three different time intervals were considered: (0-42; 43-56; > 57 days). A time interval > 57 days was significantly protective for AD (p = 0.04, Odds ratio = 0.35; 95% CI 0.1254-0.9585) without influence on early oncological outcomes. Optimal time interval after end of NRCT and surgery may help achieving the best pathological response with lowest postoperative morbidity.Trial registration number: Clinical Trial. Gov NCT04013347. https://clinicaltrials.gov/ct2/results?cond=&term=NCT04013347&cntry=&state=&city=&dist= ).
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Matsunaga R, Kojima M, Nishizawa Y, Yokota M, Hasegawa H, Saito N, Ito M, Ochiai A. The utility of longitudinal slicing method for rectal specimen: pathological analysis of circumferential resection margin of intersphincteric resection for low‐lying rectal cancer. Pathol Int 2019; 69:272-281. [DOI: 10.1111/pin.12797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/03/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Rie Matsunaga
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Motohiro Kojima
- Pathology DivisionResearch Center for Innovative Oncology, National Cancer Center Hospital EastChiba Japan
| | - Yuji Nishizawa
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Mitsuru Yokota
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Hiro Hasegawa
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Norio Saito
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Masaaki Ito
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Atsushi Ochiai
- Pathology DivisionResearch Center for Innovative Oncology, National Cancer Center Hospital EastChiba Japan
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6
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Vuijk FA, Hilling DE, Mieog JSD, Vahrmeijer AL. Fluorescent-guided surgery for sentinel lymph node detection in gastric cancer and carcinoembryonic antigen targeted fluorescent-guided surgery in colorectal and pancreatic cancer. J Surg Oncol 2018; 118:315-323. [PMID: 30216455 PMCID: PMC6175076 DOI: 10.1002/jso.25139] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022]
Abstract
Sentinel lymph node procedures for gastric cancer resections using indocyanine green (ICG) linked to Nanocoll outperformed normal ICG but did not provide information on possible lymph node metastasis. Carcinoembryonic antigen targeted fluorescent imaging using SGM‐101 was successful in both pancreatic and colorectal cancer. A large phase III multicentre trial will soon be initiated in colorectal cancer patients.
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Affiliation(s)
- Floris A Vuijk
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Lakkis Z, Panis Y. Is There Any Reason Not to Perform Standard Laparoscopic Total Mesorectal Excision? Clin Colon Rectal Surg 2017; 30:333-338. [PMID: 29184468 DOI: 10.1055/s-0037-1606110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The curative treatment of locally advanced rectal cancer is currently based on chemoradiotherapy and total mesorectal excision (TME). Laparoscopy has developed considerably because of obvious clinical benefits such as reduced pain and shorter hospital stay. Recently, several prospective randomized clinical trials with long-term follow-up have showed that laparoscopy is noninferior to laparotomy with the same oncologic outcomes in terms of survival and local control rate. However, laparoscopic TME remains a challenging procedure requiring a high level of expertise and a long learning curve to ensure an adequate and safe resection. The only relative contraindication of laparoscopic rectal surgery is T4 rectal cancer extended beyond the plane of TME. In this situation, it is reasonable to consider an open resection to avoid an uncomplete resection. In obese and elderly patients, laparoscopic TME also provides the same benefits as in nonobese and younger patients but may be more difficult to achieve. This review summarizes current knowledge on the place of laparoscopic TME in the treatment of rectal cancer.
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Affiliation(s)
- Zaher Lakkis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, University Denis-Diderot (Paris 7), Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, University Denis-Diderot (Paris 7), Clichy, France
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Beaufrère A, Guedj N, Maggiori L, Patroni A, Bedossa P, Panis Y. Circumferential margin involvement after total mesorectal excision for mid or low rectal cancer: are all R1 resections equal? Colorectal Dis 2017; 19:O377-O385. [PMID: 28941054 DOI: 10.1111/codi.13895] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Abstract
AIM Our aim was to assess the prognostic influence of the circumferential resection margin (CRM) exact value after total mesorectal excision for mid or low rectal cancer. METHODS All patients (n = 321) who underwent total mesorectal excision from 2005 to 2013 were identified from a prospective database, including 49 (15%) who presented with a CRM ≤ 1 mm. Four groups were defined: group 1, CRM = 0 mm (n = 21); group 2, 0 < CRM ≤ 0.4 mm (n = 13); group 3, 0.4 < CRM ≤ 1 mm (n = 15); group 4, CRM > 1 mm (n = 272). RESULTS After a mean follow-up of 42 ± 26 months, locoregional recurrence rates were 8/21 (38%) in group 1, 3/13 (23%) in group 2, 0/12 (0%) in group 3 and 26/272 (10%) in group 4 (P < 0.001), leading to significantly impaired 3-year locoregional recurrence-free survival in group 1 (57% ± 13%) and group 2 (56% ± 15%) compared to group 3 (85% ± 10%, vs group 1, P = 0.021, vs group 2, P = 0.049) and to group 4 (89% ± 2%, vs group 1, P < 0.001, vs group 2, P < 0.001). In multivariate Cox analysis, a CRM ≤ 0.4 mm was identified as an independent factor impairing both locoregional recurrence-free survival (OR 3.14, 95% CI 1.53-6.46; P = 0.002) and disease-free survival (OR 2.15, 95% CI 1.28-3.63; P = 0.004). CONCLUSION Our study suggests that the prognosis after mid or low rectal cancer surgery was worse with a CRM ≤ 0.4 mm. The prognosis was similar in patients with a CRM > 0.4 mm or ≤ 1 mm and patients with an R0 resection.
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Affiliation(s)
- A Beaufrère
- Department of Pathology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - N Guedj
- Department of Pathology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - L Maggiori
- Colorectal Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - A Patroni
- Colorectal Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - P Bedossa
- Department of Pathology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy, France
| | - Y Panis
- Colorectal Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy, France
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9
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Aslan D, Bordea A, Burcoș T. Anastomotic leakage after sphincter-sparing surgery in a young woman diagnosed with low rectal cancer - case report. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2017. [DOI: 10.25083/2559.5555.21.4553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rectal cancer is the third most common site for cancer in the world, with a high morbidity and mortality. The new techniques for the treatment of low rectal cancer have been improved recently, allowing sphincter-sparing surgery to be available for more patients, with an optimal oncological and functional outcome. The most fundamental advance in rectal cancer surgery was the concept of total mesorectal resection (TME) introduced by Heald in 1982. Association with neoadjuvant radio-chemotherapy determines regression of the disease by “down staging” the tumors and allows for sphincter-sparing surgery to be performed, with low recurrence rate and increased overall survival. We present the case of 48-year old woman who had low rectal resection with colorectal anastomosis for middle rectal cancer. The patient had a BMI of 29, was hypertensive, had uterine fibroids and underwent neoadjuvant radiotherapy. During the 4th postoperative day the patient developed an anastomotic leakage grade B which was spontaneously closed on the 15th postoperative day. The patient did not manifest fever or any other symptoms. Normal bowel function resumed on the 5th postoperative day. No recurrence was detected at the one-year follow-up.
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Kusters M, Slater A, Betts M, Hompes R, Guy RJ, Jones OM, George BD, Lindsey I, Mortensen NJ, James DR, Cunningham C. The treatment of all MRI-defined low rectal cancers in a single expert centre over a 5-year period: is there room for improvement? Colorectal Dis 2016; 18:O397-O404. [PMID: 27313145 DOI: 10.1111/codi.13409] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/08/2016] [Indexed: 12/13/2022]
Abstract
AIM Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition. METHOD A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database. RESULTS One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response. CONCLUSION In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers.
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Affiliation(s)
- M Kusters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands. .,Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
| | - A Slater
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Betts
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - O M Jones
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B D George
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - I Lindsey
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D R James
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Gravante G, Hemingway D, Stephenson JA, Sharpe D, Osman A, Haines M, Pirjamali V, Sorge R, Yeung JM, Norwood M, Miller A, Boyle K. Rectal cancers with microscopic circumferential resection margin involvement (R1 resections): Survivals, patterns of recurrence, and prognostic factors. J Surg Oncol 2016; 114:642-648. [DOI: 10.1002/jso.24360] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/20/2016] [Indexed: 01/27/2023]
Affiliation(s)
- Gianpiero Gravante
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - David Hemingway
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | | | - David Sharpe
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - Ahmed Osman
- Department of Oncology; Leicester Royal Infirmary; Leicester United Kingdom
| | - Melissa Haines
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - Vafa Pirjamali
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - Roberto Sorge
- Laboratory of Biometry; Department of Human Physiology; University of Tor Vergata; Rome Italy
| | - Justin Ming Yeung
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - Michael Norwood
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - Andrew Miller
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
| | - Kirsten Boyle
- Department of Colorectal Surgery; Leicester Royal Infirmary; Leicester United Kingdom
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