Can rectal washout reduce anastomotic recurrence after anterior resection for rectal cancer? A review of the literature

Cytological Analysis of the Surgical Field During Transanal Total Mesorectal Excision for Rectal Cancer: A Prospective Study

BACKGROUND

An unexpectedly large number of patients experienced local recurrence with transanal total mesorectal excision in Norway. This appears to be associated with cancer cell spillage during surgery.

OBJECTIVE

To investigate the surgical field cytology during transanal total mesorectal excision.

DESIGN

This was a prospective cohort study.

SETTINGS

This study was conducted at a single center between June and December 2020.

PATIENTS

Forty patients with rectal cancer underwent transanal total mesorectal excision. After irrigation of the surgical field, the water specimens were cytologically evaluated at 6 representative steps. The first sample was used as an initial control. The second, third, fourth, fifth, and sixth samples were collected after the first pursestring suture, rectotomy, the second pursestring suture, specimen resection, and anastomosis, respectively. The clinicopathological features and intraoperative complications of the patients were reviewed.

MAIN OUTCOME MEASURES

The primary outcome was to evaluate the presence of cancer cells in washing cytological samples.

RESULTS

Of the 40 consecutive patients enrolled in this study, 18 patients underwent neoadjuvant chemoradiotherapy. Incomplete first pursestring suture and rectal perforation were observed in 4 (10.0%) and 3 (7.5%) cases, respectively. In the first sample, 31 patients (77.5%) had malignant cells. Malignant findings were detected in 2 patients (5.0%) from the second to fifth samples. None of the sixth sample exhibited any malignant findings.

LIMITATIONS

This single-center study had a small sample size.

CONCLUSIONS

Cancer cells were initially detected by cytology, but only a few were observed throughout the procedure; however, cancer cells were not detected in the final surgical field. Further follow-up and novel studies are required to obtain clinically significant findings using cytology during transanal total mesorectal excision. See Video Abstract .

ANLISIS CITOLGICO DEL CAMPO QUIRRGICO DURANTE LA ESCISIN TOTAL DEL MESORRECTO TRANSANAL PARA EL CNCER DE RECTO UN ESTUDIO PROSPECTIVO

ANTECEDENTES:Un número inesperadamente grande de pacientes experimentó recurrencia local con la escisión total del mesorrecto transanal en Noruega. Esto parece estar asociado con el derrame de células cancerosas durante la cirugía.OBJETIVO:Investigar la citología del campo quirúrgico durante la escisión total del mesorrecto transanal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Este estudio se realizó en un solo centro entre junio y diciembre de 2020.PACIENTES:Cuarenta pacientes con cáncer de recto se sometieron a escisión total del mesorrecto transanal. Después de la irrigación del campo quirúrgico, las muestras de agua se evaluaron citológicamente en seis pasos representativos. La primera muestra se utilizó como control inicial. La segunda, tercera, cuarta, quinta y sexta muestras se recolectaron después de la primera sutura en bolsa de tabaco, la rectotomía, la segunda sutura en bolsa de tabaco, la resección de la muestra y la anastomosis, respectivamente. Se revisaron las características clínico-patológicas y las complicaciones intraoperatorias de los pacientes.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la presencia de células cancerosas en el lavado de muestras citológicas.RESULTADOS:De los 40 pacientes consecutivos inscritos en este estudio, 18 pacientes se sometieron a quimiorradioterapia neoadyuvante. Se observaron la primera sutura en bolsa de tabaco incompleta y perforación rectal en cuatro (10,0%) y tres (7,5%) casos, respectivamente. En la primera muestra, 31 (77,5%) pacientes tenían células malignas. Se detectaron hallazgos malignos en dos pacientes (5,0%) de la segunda a la quinta muestra. Ninguno de la sexta muestra demostraron hallazgos malignos.LIMITACIONES:Este estudio unicéntrico tuvo un tamaño de muestra pequeño.CONCLUSIONES:Inicialmente se detectaron células cancerosas mediante citología, pero solo se observaron unas pocas durante todo el procedimiento; sin embargo, no se detectaron células cancerosas en el campo quirúrgico final. Se requieren más seguimientos y estudios novedosos para obtener hallazgos clínicamente significativos mediante citología durante la escisión total del mesorrecto transanal. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Intraoperative esophageal washout reduces free intraluminal tumor cells during resection of carcinomas of the esophagus and cardia

OBJECTIVE

Intraluminally shed viable tumor cells might contribute to anastomotic recurrence in cancer of the esophagus and the cardia. The study aimed to establish a method of esophageal washout and, hence, to reduce intraluminal cancer cells before esophageal anastomosis.

METHODS

Forty-eight consecutive patients with esophago-gastric resection for histologically proven cancer of the esophagus or the cardia were included in a prospective, interventional study. Before transection, the esophagus was clamped proximally to the tumor and rinsed with 1:10 diluted povidone-iodine-solution (10 × 30 ml) applied by a transorally inserted 24F-Foley catheter. The first, fifth and tenth portion of the lavage fluid were sent to cytological examination.

RESULTS

Intraoperative frozen sections confirmed clear proximal resection margins of the esophagus. The cytological examination of the fluid recovered from the esophageal washout revealed malignant cells in 13/48 patients (27%). The presence of malignant cells was significantly less likely in patients with neoadjuvant treatment than in patients without neoadjuvant treatment: 2/23 (9%) vs. 11/25 (44%) (p = 0.009). Repetitive washout reduced the probability of detectable malignant cells from 13 to 8 (62%) patients after 5, and further to 4 patients (30%) after 10 washout maneuvers.

CONCLUSIONS

Free malignant cells may be present in the esophageal lumen following intraoperative manipulation of cancers of the esophagus or cardia. Transoral washout of the esophagus is novel, feasible and enables reduction or even elimination of these tumor cells. The reliability of this procedure raises with increasing washout volume. Esophageal washout might be especially worthwhile in patients who do not receive neoadjuvant therapy.

Mueller matrix polarization parameters correlate with local recurrence in patients with stage III colorectal cancer

The peri-tumoural stroma has been explored as a useful source of prognostic information in colorectal cancer. Using Mueller matrix (MM) polarized light microscopy for quantification of unstained histology slides, the current study assesses the prognostic potential of polarimetric characteristics of peri-tumoural collagenous stroma architecture in 38 human stage III colorectal cancer (CRC) patient samples. Specifically, Mueller matrix transformation and polar decomposition parameters were tested for association with 5-year patient local recurrence outcomes. The results show that some of these polarimetric parameters were significantly different (p value < 0.05) for the recurrence versus the no-recurrence patient cohorts (Mann-Whitney U test). MM parameters may thus be prognostically valuable towards improving clinical management/treatment stratification in CRC patients.

Implantation metastasis from sigmoid colon cancer to rectal anastomosis proved by whole exome sequencing and lineage inference for cancer heterogeneity and evolution analysis: Case report and literature review

It was estimated that 70% of patients with colorectal cancer were found to have viable exfoliated malignant cells in adjacent intestinal lumen. Exfoliated malignant cells had been reported to implant on raw surfaces, such as polypectomy site, anal fissure, anal fistula, hemorrhoidectomy wound, and anastomotic suture line. Tumors at anastomosis could be classified into four groups: local recurrence, local manifestation of widespread metastasis, metachronous carcinogenesis, and implantation metastasis. However, all of the previous studies only reported the phenomena of implantation metastasis at anastomosis. No study had proved the origin of anastomotic metastasis by genomic analysis. In this study, a 43-year-old woman presented with persistent hematochezia was diagnosed as having severe mixed hemorrhoids. She was treated by procedure for prolapse and hemorrhoids (PPH), without receiving preoperative colonoscopy. Two months later, she was found to have sigmoid colon cancer by colonoscopy due to continuous hematochezia and received radical sigmoidectomy. Postoperative histological examination confirmed the lesion to be a moderately differentiated adenocarcinoma (pT3N1M0). Six months later, she presented with hematochezia again and colonoscopy revealed two tumors at the rectal anastomosis of PPH. Both tumors were confirmed to be moderately differentiated adenocarcinoma without lymph node and distant metastasis and were finally removed by transanal endoscopic microsurgery (TEM). Pathological examination, whole exome sequencing (WES), and Lineage Inference for Cancer Heterogeneity and Evolution (LICHeE) analysis demonstrated that the two tumors at the rectal anastomosis were probably implantation metastases arising from the previous sigmoid colon cancer. This is the first study to prove implantation metastasis from colon cancer to a distal anastomosis by WES and LICHeE analysis. Therefore, it is recommended to rule out colorectal cancer in proximal large bowel before performing surgery with a rectal anastomosis, such as PPH and anterior resection. For patients with a suspected implanted tumor, WES and LICHeE could be used to differentiate implantation metastasis from metachronous carcinogenesis.

Rectal washout during abdominoperineal resection for rectal cancer has no impact on the oncological outcome

AIM

Intraoperative rectal washout is performed to eliminate exfoliated intraluminal cancer cells and thereby decrease the risk of local recurrence. Rectal washout in abdominoperineal resection has not been studied. The aim of this study was to assess the oncological outcome after rectal washout in abdominoperineal resection for rectal cancer and to find evidence as to whether rectal washout should be performed or not.

METHOD

Data for all patients registered in the Swedish Colorectal Cancer Registry who underwent elective surgery with abdominoperineal resection for rectal cancer (TNM Stages I-III) between 2007 and 2013 were analysed using multivariable analysis.

RESULTS

No significant differences were shown between the rectal washout group and the no rectal washout group for local recurrence [10/265 (3.8%) vs. 87/2160 (4.0%), p = 0.84], distant metastasis [51/265 (19.2%) vs. 476/2160 (22.0%), p = 0.29] or overall recurrence [53/265 (20.0%) vs. 505/2160 (23.4%), p = 0.21]. In multivariable analysis, rectal washout did not significantly affect the oncological outcome in terms of local recurrence, distant metastasis, overall recurrence or 5-year overall or relative survival.

CONCLUSION

Our results do not support routine rectal washout during abdominoperineal resection in order to improve the oncological outcome.

Local recurrence at the site of the Lone Star device through implantation of exfoliated cells during local excision for early rectal cancer: A case report

Introduction

Invasive procedures for colorectal cancer can cause iatrogenic tumor cell seeding. Implantation of these exfoliated cells in the surrounding tissue can result in locoregional cancer recurrence. This has been described in endoscopic procedures and major surgical resections, however recurrence in iatrogenic lesions of the anal canal during minimal invasive rectal surgery has not been shown in literature yet. This is the first reported case of recurrent rectal cancer that developed into an anal metastasis at the site where hooks of the Lone Star Retractor disrupted the epithelial lining of the anal canal during a local excision of early rectal cancer using TAMIS.

Presentation of case

A 57 year old male was diagnosed with a high risk early stage rectal adenocarcinoma. He was treated with transanal minimally invasive surgery (TAMIS) with the use of a Lone Star retractor and he received subsequent chemo-radiotherapy. 23 months later the patient developed a bleeding mass bulging out of the anus. A true cut and incision biopsy was performed and the pathology report revealed localization of adenocarcinoma at the anal canal which was similar to the earlier diagnosed rectal carcinoma. The patient underwent an abdominal perineal resection and left-sided lymph node dissection.

Discussion and conclusion

This shows that local recurrence through implantation of exfoliated tumor cells can occur in iatrogenic lesions of the anal canal not only in major but also in minimal invasive rectal surgery. Careful tissue handling and rectal washout may reduce the chance of this implantation metastasis.

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Recurrent rectal cancer can occur at the site of an iatrogenic anal lesion.

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Anal metastasis can develop due to implantation of exfoliated rectal tumor cells.

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Iatrogenic local recurrence occurs in both major rectal surgery and local excision.

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Careful tissue handling and rectal washout may reduce the chance of recurrence.

Recurrence of sigmoid colon cancer–derived anal metastasis: A case report and review of literature

BACKGROUND

Distant metastasis of colorectal cancer to the anus is very rare, with only 30 related cases published in PubMed thus far. Therefore, recurrence of colorectal cancer derived anus metastases is rarely seen and less presented.

CASE SUMMARY

Here we report an 80-year-old male patient who underwent radical resection for sigmoid colon cancer in January 2010 and another surgery for anal fistula resection in December 2010. Postoperative pathology of the anal fistula revealed a metastatic moderately differentiated adenocarcinoma. The patient subsequently received chemotherapy and radiotherapy. In May 2020, after the patient reported symptoms of anal swelling and pain, computed tomography and magnetic resonance imaging revealed a perianal abscess. Perianal mass biopsy was performed, and the postoperative pathological diagnosis was metastatic moderately differentiated adenocarcinoma.

CONCLUSION

This case highlights that there is a risk of recurrence of anal metastasis of colorectal cancer even after 10 years of follow-up. We also reviewed the literature and discuss potential mechanisms for anal metastasis of colorectal cancer, thus providing some suggestions for treatment of these cases.

Combined mechanical and oral antibiotic bowel preparation is associated with prolonged recurrence-free survival following surgery for colorectal cancer

BACKGROUND AND OBJECTIVES

Recent studies suggest that bacteria influence the pathogenesis of primary colorectal cancer (CRC), yet their role in recurrence after resection is largely unknown. We have discovered that collagenase-producing bacteria promote cancer recurrence in mice, and that antibiotic bowel decontamination decreases colonization of these same organisms in humans. We hypothesized that preoperative combined mechanical and oral antibiotic bowel preparation would improve disease-free survival (DFS) in patients undergoing surgery for CRC.

METHODS

We reviewed a cancer registry of patients treated for CRC at a tertiary center. Patients who received bowel preparation were compared to those that did not via a 1:1-propensity score matched for follow-up, age, sex, BMI, stage, location, chemoradiation, infection, anastomotic leak, and blood transfusion.

RESULTS

One thousand two hundred and seventy-nine patients met inclusion criteria. Following propensity score matching, 264 patients receiving bowel prep were matched to 264 patients who did not. Kaplan-Meier estimates showed that patients who received bowel prep had a significantly improved 5-year DFS compared to those that did not (76.3% vs. 64.2%; p < .01). Cox regression demonstrated that bowel prep was associated with improved DFS (HR, 0.57; 95% CI, 0.37-0.89; p < .01).

CONCLUSION

Combined mechanical and oral antibiotic bowel preparation is independently associated with improved recurrence-free survival in patients undergoing surgery for CRC.

Rectal washout does not increase the complication risk after anterior resection for rectal cancer

Background

To reduce local recurrence risk, rectal washout (RW) is integrated in the total mesorectal excision (TME) technique when performing anterior resection (AR) for rectal cancer. Although RW is considered a safe practice, data on the complication risk are scarce. Our aim was to examine the association between RW and 30-day postoperative complications after AR for rectal cancer.

Methods

Patients from the Swedish Colorectal Cancer Registry who underwent AR between 2007 and 2013 were analysed using multivariable methods.

Results

A total of 4821 patients were included (4317 RW, 504 no RW). The RW group had lower rates of overall complications (1578/4317 (37%) vs. 208/504 (41%), p = 0.039), surgical complications (879/4317 (20%) vs. 140/504 (28%), p < 0.001) and 30-day mortality (50/4317 (1.2%) vs. 12/504 (2.4%), p = 0.020). In multivariable analysis, RW was a risk factor neither for overall complications (OR 0.73, 95% CI 0.60–0.90, p = 0.002) nor for surgical complications (OR 0.62, 95% CI 0.50–0.78, p < 0.001).

Conclusions

RW is a safe technique that does not increase the 30-day postoperative complication risk after AR with TME technique for rectal cancer.