Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer

Comparison of outcomes of abdominoperineal resection vs low anterior resection in very-low rectal cancer

BACKGROUND

The management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal resection (APR) over low anterior resection (LAR) to optimize oncologic outcomes. This study aimed to determine differences in long-term oncologic outcomes between patients undergoing APR or LAR for very-low rectal cancer.

METHODS

The United States Rectal Cancer Consortium (2010-2016) was queried for adults who underwent either APR or LAR for stage I-III rectal cancers < 5 cm from anorectal junction and met inclusion criteria. The primary outcome was disease-free survival. Secondary outcomes included overall survival, length of stay, complications, recurrence location, and perioperative factors.

RESULTS

A total of 431 patients with very-low rectal cancer who underwent APR or LAR were identified; 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. The median follow-up was 42.5 months. An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types (APR-hazard ratio [HR] = 0.90, 95% CI: 0.53-1.52, P = .70). Secondary outcomes demonstrated no significant difference between operation types, including overall survival (HR = 1.29, 95% CI: 0.71-2.32, P = .39), complications (OR = 1.53, 95% CI: 0.94-2.50, P = .12), or length of stay (estimate: 0.04, SE = 0.25, P = .54).

CONCLUSION

We observed no significant difference in disease-free survival or overall survival between patients undergoing APR or LAR for very-low rectal cancer. This analysis supports the treatment of very-low rectal cancer, without sphincter involvement, by either APR or LAR.

Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

Robotic vs laparoscopic abdominoperineal resection for rectal cancer: A propensity score matching cohort study and meta-analysis

BACKGROUND

Robotic surgery (RS) is gaining popularity; however, evidence for abdominoperineal resection (APR) of rectal cancer (RC) is scarce.

AIM

To compare the efficacy of RS and laparoscopic surgery (LS) in APR for RC.

METHODS

We retrospectively identified patients with RC who underwent APR by RS or LS from April 2016 to June 2022. Data regarding short-term surgical outcomes were compared between the two groups. To reduce the effect of potential confounding factors, propensity score matching was used, with a 1:1 ratio between the RS and LS groups. A meta-analysis of seven trials was performed to compare the efficacy of robotic and laparoscopic APR for RC surgery.

RESULTS

Of 133 patients, after propensity score matching, there were 42 patients in each group. The postoperative complication rate was significantly lower in the RS group (17/42, 40.5%) than in the LS group (27/42, 64.3%) (P = 0.029). There was no significant difference in operative time (P = 0.564), intraoperative transfusion (P = 0.314), reoperation rate (P = 0.314), lymph nodes harvested (P = 0.309), or circumferential resection margin (CRM) positive rate (P = 0.314) between the two groups. The meta-analysis showed patients in the RS group had fewer positive CRMs (P = 0.04), lesser estimated blood loss (P < 0.00001), shorter postoperative hospital stays (P = 0.02), and fewer postoperative complications (P = 0.002) than patients in the LS group.

CONCLUSION

Our study shows that RS is a safe and effective approach for APR in RC and offers better short-term outcomes than LS.

Outcomes of Early Versus Standard Closure of Diverting Ileostomy After Proctectomy: Meta-analysis and Meta-regression Analysis of Randomized Controlled Trials

OBJECTIVE

We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications.

BACKGROUND

Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL.

METHODS

PubMed, Scopus, and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection, reoperation, readmission, and hospital stay following DLI closure.

RESULTS

Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL [odds ratio (OR): 2.315, P =0.013] and similar odds of complications (OR: 1.103, P =0.667), ileus (OR: 1.307, P =0.438), surgical site infection (OR: 1.668, P =0.079), reoperation (OR: 1.896, P =0.062), and readmission (OR: 3.431, P =0.206). Hospital stay was similar (weighted mean difference: 1.054, P =0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P =0.047) but not within 3 to 4 weeks (OR: 2.98, P =0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks, whereas factors associated with AL were ≥ American Society of Anesthesiologists II classification and diabetes mellitus.

CONCLUSIONS

Early closure of DLI after proctectomy has a higher risk of AL, particularly within 2 weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.

Perioperative outcomes in male patients undergoing cystectomy, radical colorectal procedure or total pelvic exenteration

Background

Total pelvic exenteration (TPE) in men is a surgical procedure to treat genitourinary and colorectal malignancies. Despite improvement in multimodal strategies and technology, mortality is still high and literature is limited about perioperative outcomes comparison to other radical procedures.

Methods

We analyzed National Surgical Quality Improvement Program (NSQIP) baseline database of all male patients undergoing cystectomy, low anterior resection/abdominoperineal resection (LAR/APR) or TPE from January 1, 2005 to December 31, 2016. Postoperative complications within 30 days after surgery were measured including: Wound infection, septic complications, deep vein thrombosis, cardiovascular events, and return to the operating room or mortality, etc. Differences between groups were analyzed using analysis of variance (ANOVA) tests.

Results

A total of 7,375 patients underwent radical cystectomy, 49,762 underwent LAR/APR and 792 underwent TPE. Cystectomy patients were on average older compared to TPE or LAR/APR patients (P<0.001). In univariable and multivariable analysis, patients undergoing TPE had greater infectious and septic complications compared to cystectomy (odds ratio =1.09; 95% confidence interval (CI): 1.06-1.12) and LAR/APR (odds ratio =1.08; 95% CI: 1.05-1.11). Moreover, TPE had a slightly higher mortality within the 30-day postoperatively than those who underwent LAR/APR (odds ratio =1.01; 95% CI: 1.00-1.02) and cystectomy (odds ratio =1.01; 95% CI: 1.00-1.01).

Conclusions

Men undergoing TPE had greater rates of infections and postoperative complications compared to those undergoing radical cystectomy and LAR/APR. From a clinical standpoint, TPE has high morbidity that could provide opportunity for quality improvement projects with the goal of mitigating high complication rates.

Management of primary anorectal mucosal melanoma during the COVID-19 pandemic

Anorectal melanoma is a rare and difficult-to-diagnose highly malignant cancer with a poor prognosis. The treatment usually involves surgery and often includes adjuvants such as radiation therapy and immunotherapy. We present a case of a 77-year-old Peruvian who was eventually diagnosed with this cancer during the COVID-19 pandemic, which complicated her treatment and allowed the cancer to spread. Her treatment included abdominoperineal resection, bilateral pelvic lymphadenectomy, left internal iliac vein raffia and end colostomy, followed by 3D radiation therapy (50 Gy, 25 sessions) and systemic treatment with nivolumab, all of which were well tolerated. The patient was alive as of 20 August 2023, having survived for more than 3 years since the onset of symptoms.

Effects of a bowel function improvement program for patients with rectal cancer surgery: A randomized controlled trial

OBJECTIVES

This study aimed to examine the effectiveness of a bowel function improvement program for male patients with rectal cancer who underwent low anterior resection.

METHODS

A prospective, unblinded, and randomized controlled trial was conducted. The enrolled 42 patients were assigned to the experimental or control group at a 1:1 ratio. The bowel function improvement program comprised a 4-week intensive program (face-to-face education and telephone coaching) and an 8-week maintenance program (text messages). Self-efficacy, bowel function, health-related quality of life, and healthcare resource utilization were measured. Collected data were analyzed using independent t-tests, chi-square tests, analysis of covariance, and generalized estimation equations to evaluate the effects of the program based on intention-to-treat.

RESULTS

The bowel function improvement program was effective in improving bowel function 3 months after discharge. Additionally, the number of unplanned pharmacy visits was lower in the experimental group than in the control group. Health-related quality of life, self-efficacy, and utilization of other healthcare resources were not statistically or clinically significant.

CONCLUSION

These findings indicated that the bowel function improvement program for male patients with rectal cancer was effective in improving bowel function and reducing unplanned healthcare resource utilization. The bowel function improvement program can be delivered as a nurse-led program in clinical practice to promote early recovery after low anterior resection.

TRIAL REGISTRATION NUMBER

KCT0003505. https://cris.nih.go.kr/cris/search/detailSearch.do/13708.

The erectile and ejaculatory implications of the surgical management of rectal cancer

Colorectal cancer is a significant cause of cancer-related deaths worldwide. Although advances in surgical technology and technique have decreased mortality rates, surviving patients often experience sexual dysfunction as a common complication. The development of the lower anterior resection has greatly decreased the use of the radical abdominoperineal resection surgery, but even the less radical surgery can result in sexual dysfunction, including erectile and ejaculatory dysfunction. Improving the knowledge of the underlying causes of sexual dysfunction in this context and developing effective strategies for preventing and treating these adverse effects are essential to improving the quality of life for postoperative rectal cancer patients. This article aims to provide a comprehensive evaluation of erectile and ejaculatory dysfunction in postoperative rectal cancer patients, including their pathophysiology and time course and strategies for prevention and treatment.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision

OBJECTIVES

the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE).

METHODS

we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin.

RESULTS

sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239).

CONCLUSION

rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

Gluteal Propeller Perforator Flaps: A Paradigm Shift in Abdominoperineal Amputation Reconstruction

Abdominoperineal amputation (AAP) is a gold standard procedure treating advanced abdominal and pelvic cancers. The defect resulting from this extensive surgery must be reconstructed to avoid complications, such as infection, dehiscence, delayed healing, or even death. Several approaches can be chosen depending on the patient. Muscle-based reconstructions are a reliable solution but are responsible for additional morbidity for these fragile patients. We present and discuss our experience in AAP reconstruction using gluteal-artery-based propeller perforator flaps (G-PPF) in a case series. Between January 2017 and March 2021, 20 patients received G-PPF reconstruction in two centers. Either superior gluteal artery (SGAP)- or inferior artery (IGAP)-based perforator flaps were performed depending on the best configuration. Preoperative, intraoperative, and postoperative data were collected. A total of 23 G-PPF were performed-12 SGAP and 11 IGAP flaps. Final defect coverage was achieved in 100% of cases. Eleven patients experienced at least one complication (55%), amongst whom six patients (30%) had delayed healing, and three patients (15%) had at least one flap complication. One patient underwent a new surgery at 4 months for a perineal abscess under the flap, and three patients died from disease recurrence. Gluteal-artery-based propeller perforator flaps are an effective and modern surgical procedure for AAP reconstruction. Their mechanic properties, in addition to their low morbidity, make them an optimal technique for this purpose; however, technical skills are needed, and closer surveillance with patient compliance is critical to ensure success. G-PPF should be widely used in specialized centers and considered a modern alternative to muscle-based reconstructions.

Analysis of Survival in Complete Pathological Response after Long-Course Chemoradiotherapy in Patients with Advanced Rectal Cancer

BACKGROUND

Neoadjuvant chemoradiotherapy prior to surgery is the standard treatment for locally advanced rectal cancer. This consists in the patient's complete pathological response being achieved with no residual tumor presence in the resected specimen, which results in survival improvement.

METHODS

This retrospective study aimed to examine the rate of complete pathological response in patients with advanced rectal cancer treated with neoadjuvant long-course chemoradiotherapy and to examine the survival differences between the different tumor regression grade (TRG) scores.

RESULTS

A total of 154 patients were operated prior to long-course chemoradiotherapy with a total of 50 Gy plus FOLFOX protocol. Complete pathologic response was achieved in 29 (18.8%) patients. There was no statistical difference for the different pathologic responses according to gender, type of surgery, and number of harvested lymph nodes. Mean survival for all the groups was 37.2 months. Survival within a different TRG score exhibited statistical significance (p = 0.006). Overall, the survival rate during the follow-up period was of 81.8%.

CONCLUSIONS

The complete pathological response rate in this study was of 18.8%. High tumor regression grade scores (TRG0 and TRG1) had a survival rate of over 90% during follow-up. Multivariate analysis identified perineural invasion and tumor regression grade as independent factors that affect survival.

Trends of sphincter-preserving surgeries for low lying rectal cancer: A 20-year experience in China

Background

Over the last 2 decades, patients with low rectal cancer have had better outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trends in sphincter-preserving surgeries for low rectal cancer over 20 years in a top tertiary hospital in China.

Methods

Between 1999 and 2021, a cohort of patients with primary malignant rectal tumor ≤5cm from the anal verge and who received elective surgeries at Changhai Hospital, Shanghai, China, was identified. Data were extracted from electronic medical records. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). Adjusted Cox proportional hazards regression model was used to assess overall survival.

Results

Among a total of 4,172 patients during the study period, 3,111 (74.6%) underwent a sphincter-preserving surgery and 1,061 (25.4%) received APR. Sphincter-preserving surgery increased 3.6% per year (95%CI, 2.3-4.9). Low anterior resection was the most performed procedure (86.3%) and maintained a steady trend, while intersphincteric resection increased 49.4% annually (95%CI, 19.5-86.7) after initiation. Laparoscopic techniques increased 15.1% per year (95%CI, 8.4-43.4) after initiation. Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-≤3cm and 3-≤4cm from the anal verge (AAPC 7.1, 4.5-9.8; 4.7, 3.1-6.3; 2.7, 1.7-3.6, respectively). Furthermore, patients with sphincter-preserving surgery had a better overall survival than abdominoperineal resection (APR) patients (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01).

Conclusions

Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.

Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study

AIM

The main objective of this study was to compare the oncological outcomes of patients undergoing abdominoperineal resection (APR) versus low anterior resection (LAR) through a transanal total mesorectal excision (taTME) approach.

METHOD

A total of 360 adult patients with a diagnosis of rectal cancer were enrolled at participating centres from the Canadian taTME Expert Collaboration. Forty-three patients received taTME-APR and received 317 taTME-LAR. Demographic, operative, pathological and follow-up data were collected and merged into a single database. Results are presented as hazard ratio (HR) and 95% confidence interval. All analyses were performed in the R environment (v.3.6).

RESULTS

The proportion of patients with a positive circumferential radial margin status was higher in the taTME-APR group than the taTME-LAR group (21% vs. 9%, p = 0.001). Complete TME was achieved in 91% of those undergoing APR compared with 96% of those undergoing LAR (p = 0.25). APR was associated with a greater rate of local recurrence relative to LAR, although it was not significant [crude HR = 3.53 (95% CI 0.92-13.53)]. Circumferential margin positivity was significantly associated with a higher rate of systemic recurrence [crude HR = 3.59 (95% CI 1.38-9.3)].

CONCLUSION

Our results demonstrate inferior outcomes in those undergoing taTME-APR compared with taTME-LAR. The use of this technique for this particular indication needs to be carefully considered.

Communication in decision aids for stage I-III colorectal cancer patients: a systematic review

OBJECTIVES

To assess the communicative quality of colorectal cancer patient decision aids (DAs) about treatment options, the current systematic review was conducted.

DESIGN

Systematic review.

DATA SOURCES

DAs (published between 2006 and 2019) were identified through academic literature (MEDLINE, Embase, CINAHL, Cochrane Library and PsycINFO) and online sources.

ELIGIBILITY CRITERIA

DAs were only included if they supported the decision-making process of patients with colon, rectal or colorectal cancer in stages I-III.

DATA EXTRACTION AND SYNTHESIS

After the search strategy was adapted from similar systematic reviews and checked by a colorectal cancer surgeon, two independent reviewers screened and selected the articles. After initial screening, disagreements were resolved with a third reviewer. The review was conducted in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DAs were assessed using the International Patient Decision Aid Standards (IPDAS) and Communicative Aspects (CA) checklist.

RESULTS

In total, 18 DAs were selected. Both the IPDAS and CA checklist revealed that there was a lot of variation in the (communicative) quality of DAs. The findings highlight that (1) personalisation of treatment information in DAs is lacking, (2) outcome probability information is mostly communicated verbally and (3) information in DAs is generally biased towards a specific treatment. Additionally, (4) DAs about colorectal cancer are lengthy and (5) many DAs are not written in plain language.

CONCLUSIONS

Both instruments (IPDAS and CA) revealed great variation in the (communicative) quality of colorectal cancer DAs. Developers of patient DAs should focus on personalisation techniques and could use both the IPDAS and CA checklist in the developmental process to ensure personalised health communication and facilitate shared decision making in clinical practice.

Sphincter preservation in patients with low rectal cancer: striking the right oncological balance

BACKGROUND

The surgical treatment options for low rectal cancer patients include the Abdominoperineal Resection and the sphincter saving Low Anterior Resection. There is growing evidence towards better outcomes for patients being treated with a Low Anterior Resection compared to an Abdominoperineal Resection.

OBJECTIVE

The aim of this study was to evaluate the short term and oncological outcomes in low rectal cancer treatment.

DESIGN

This is a retrospective cohort study of prospectively collected data.

SETTING

Rectal cancer patients from a single center in the United Kingdom.

PATIENTS

Patients included all low rectal cancer patients (≤ 6 cm from the anal verge) undergoing Low Anterior Resection or Abdominoperineal Resection between 2006 and 2016.

OUTCOME MEASURES

To identify differences in postoperative complications and disease free and overall survival.

RESULTS

A total of 262 patients were included for analysis (Low Anterior Resection n = 170, Abdominoperineal Resection n = 92). Abdominoperineal Resection patients were significantly older (69 versus 66 years), had lower tumours (3 versus 5 cm), received more neo-adjuvant radiation, had longer hospital stay and more complications (wound infections and wound dehiscence). Low Anterior Resections had a significantly higher number of harvested lymph nodes (17 versus 12) however there was no difference in nodal involvement and R0 resection rate. No significant difference was found for recurrence, overall survival and disease free survival.

LIMITATION

Retrospective review of cancer database and single center data.

CONCLUSION

In the treatment of low rectal cancer Abdominoperineal Resection is associated with higher rates of postoperative complications and longer hospital stay compared to the Low Anterior Resection, with similar oncological outcomes.

Sphincter-saving surgery for ultra-low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long-term follow-up?

BACKGROUND

Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR).

METHODS

ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection.

RESULTS

Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%).

CONCLUSION

GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.

Distinct Prognosis of High Versus Mid/Low Rectal Cancer: a Propensity Score-Matched Cohort Study

BACKGROUND

Rectal cancers have long been treated as a single-entity disease; however, whether the prognosis of high rectal cancer (inferior margin located 10.1 to 15.0 cm from the anal verge) differs from that of mid/low rectal cancer (0 to 10.0 cm) remains disputed.

METHODS

Patients with stages I-III rectal adenocarcinomas undergoing curative-intent surgery were enrolled between 2007 and 2013 in this retrospective analysis. Exclusion criteria were neoadjuvant therapy or concurrent cancers. Propensity score matching and Cox regression analysis were performed to compare a 5-year overall and cancer-specific survival between patients with high and mid/low rectal cancer.

RESULTS

Of 613 patients who met the inclusion criteria, 199 (32.5%) and 414 (67.5%) had high and mid/low rectal cancer, respectively. After propensity score matching (187 cases for each group), the high group showed a better overall survival (70.9 vs. 56.9%, p = 0.042) and cancer-specific survival (77.4 vs. 60.3%, p = 0.028) at 5 years compared with the mid/low group with stage III disease. However, high rectal cancer did not demonstrate prognostic superiority in stages I-II disease. Multivariate analysis identified high tumor location as an independent prognostic factor for cancer-specific survival (hazards ratio = 0.422, 95% confidence interval 0.226-0.786, p = 0.007) and overall survival (hazards ratio = 0.613, 95% confidence interval 0.379-0.991, p = 0.046).

CONCLUSIONS

Patients with stage III high rectal adenocarcinoma demonstrated better overall and cancer-specific survival than those with mid/low type, and tumor location was an independent prognostic factor for patients with rectal carcinomas.

Ultralow anterior resection with implantation of gentamicin-collagen sponge and no defunctioning stoma: anastomotic leakage and local cancer relapse

Background Anterior resection with total mesorectal excision (TME) of ultralow rectal cancer may result in the increased risk of the anastomotic leakage (AL). The aim of this study was to evaluate the usefulness of the gentamicin-collagen sponge (GCS) for the protection against symptomatic AL and investigate association between AL and local relapse (LR). Patients and methods A series of 158 patients with ultralow rectal cancer was studied. All the patients underwent R0 sphincter-saving TME with anastomosis wrapping using GCS. In none of the cases a temporary protective stoma was constructed. Results AL rate was 3.2% (5/158) while median time to AL diagnosis was 5 days following surgery (range 3-15). There was no postoperative and leakage-related mortality. Patient age > 75 years and smoking were independent risk factors related to significantly increased AL rate: 12.5% vs. 0.8% (P = 0.0004) and 5.7% vs. 0% P = 0.043), respectively. LR was observed in 12% of cases. It was highly significantly more common and developed earlier in patients who have had AL when compared with non-AL group: 80% vs. 9% (P = 0.00001) and 8.5 vs. 17 months (P = 0.014), respectively. Conclusions Anastomosis wrapping with GCS after anterior resection with TME is a safe procedure resulting in the low incidence of anastomotic leakage which may be also associated with decreased risk of local relapse.

Early ambulation after colorectal oncologic resection with perineal reconstruction is safe and effective

BACKGROUND

Post-operative bedrest is common following perineal reconstruction despite little supporting data. We sought to determine the safety of early ambulation following colorectal oncologic resection and flap-based perineal reconstruction.

METHODS

A retrospective cohort study was conducted with two cohorts: standard bedrest (BC) and early ambulation (EAC). Ambulation capacity was objectively assessed. Regression analysis was performed to determine the effects of ambulation timing on 60-day reoperations or readmissions and other surgical outcomes.

RESULTS

There were 57 participants. Those in the EAC were significantly more ambulatory on post-operative days one through three (p < 0.0001). There was no significant difference in 60-day reoperations (25% BC versus 9% EAC, p = 0.14) or readmissions (33% BC versus 15% EAC, p = 0.12). Early ambulation significantly reduced minor complication rates (38% BC versus 9% EAC, p = 0.02).

CONCLUSIONS

Early ambulation following perineal reconstruction is safe and may potentially decrease wound complications.

SUMMARY AND KEYWORDS

Institution of early ambulation protocols is rapidly becoming the standard of care for many oncological surgery patients. In cases requiring perineal reconstruction with vascularized flaps, however, there is no data to uproot the historical practice of mandatory bedrest. Our study demonstrates that the benefits of early ambulation are attainable in these patients without compromising reconstructive outcomes.

Radiofrequency ablation is beneficial in simultaneous treatment of synchronous liver metastases and primary colorectal cancer

Background

In patients with resectable synchronous colorectal liver metastases (CRLM), either two-staged or simultaneous resections of the primary tumor and liver metastases are performed. Data on radiofrequency ablation (RFA) for the treatment of CRLM during a simultaneous procedure is lacking. The primary aim was to analyze short-term and long-term outcome of RFA in simultaneous treatment. A secondary aim was to compare simultaneous resection with the colorectal-first approach.

Methods

Retrospective analysis of 241 patients with colorectal cancer and synchronous CRLM between 2000–2016. Median follow-up was 36.1 months (IQR 18.2–58.8 months). A multivariable analysis was performed to analyze the postoperative morbidity, using the comprehensive complication index. A propensity matched analysis was performed to compare survival rates.

Results

In multivariable analysis, the best predictor of lower complication severity was treatment with RFA (p = 0.040). Higher complication rates were encountered in patients who underwent an abdominoperineal resection (p = 0.027) or age > 60 years (p = 0.022). The matched analysis showed comparable overall survival in RFA treated patients versus patients undergoing a liver resection with a five year overall survival of 39.4% and 37.5%, respectively (p = 0.782). In a second matched analysis, 5-year overall survival rates in simultaneously treated patients (43.8%) was comparable to patients undergoing the colorectal first approach (43.0%, p = 0.223).

Conclusions

RFA treatment of CRLM in simultaneous procedures is associated with a lower complication severity and non-inferior oncological outcome as compared to partial liver resection. RFA should be considered a useful alternative to liver resection.

A Systematic Review to Assess Resection Margin Status After Abdominoperineal Excision and Pelvic Exenteration for Rectal Cancer

OBJECTIVE

The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer.

SUMMARY OF BACKGROUND DATA

Resection margin is important to guide therapy and to evaluate patient prognosis.

METHODS

A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature.

RESULTS

The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision [hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively] and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates.

CONCLUSIONS

Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.

The anatomy of the perineal body in relation to abdominoperineal excision for low rectal cancer

AIM

Dissection of the perineal body (PB) during abdominoperineal excision (APE) for low rectal cancer is often difficult due to the lack of a natural plane of dissection. Understanding the PB and its relation to the anorectum is essential to permit safe dissection during the perineal phase of the operation and avoid damage to the anorectum and urogenital organs. This study describes the anatomy and histology of the PB relevant to APE.

METHOD

Six human adult cadaver pelvic exenteration specimens (three male, three female) from the Leeds GIFT Research Tissue Programme were studied. Paraffin-embedded mega-blocks were produced and serially sectioned at 50- and 250-μm intervals. Sections were stained by immunohistochemistry to show collagen, elastin and smooth muscle.

RESULTS

The PB was cylindrically shaped in the male specimens and wedge-shaped in the female ones. Although centrally located between the anal and urogenital triangles, it was nearly completely formed by muscle fibres derived from the rectal muscularis propria. Thick bundles of smooth muscle, mostly arising from the longitudinal muscle, inserted into the PB and levator ani muscle (LAM). The recto-urethralis muscle originated from the PB and separated the anterolateral PB from the urogenital organs.

CONCLUSION

Smooth muscle fibres derived from the rectal muscularis propria extend into the PB and LAM and appear to fix the anorectum. Dissection of the PB during APE is safe only when the smooth muscle fibres that extend into the PB are divided.

Recurrences in stage II rectal carcinoma after curative resection alone: from the viewpoint of angiogenesis

Background

Angiogenesis plays a pivotal role in malignant tumor progression. The count of blood microvessels of the tumor has been recognized as an indicator of malignant potential of the tumors and provides the ability to predict tumors recurrence. The role endoglin in the Dukes B rectal cancer is still unexplored. The aims of this study were to examine immunohistochemical expression of endoglin in resected rectal cancer and investigate the relationship of tumor recurrence and other clinicopathological variables to the endoglin-assessed microvessel density of the tumor tissue and distal resection margins.

Methods

The study included 95 primary rectal adenocarcinomas, corresponding to 95 distal and 95 proximal resection margin specimens from surgical resection samples. Tumor specimens were paraffin embedded, and immunohistochemical staining for the CD105 endothelial antigen was performed to count CD105-MVD. For exact measurement of the CD105-MVD used, a computer-integrated system Alphelys Spot Browser 2 was used.

Results

The MVD was significantly higher in the tumor samples compared with the distal resection margins (p < 0.0001) and the proximal resection margins (p < 0.0001). There was no significant difference in the MVD between distal and proximal resection margins (p = 0.147). The type of surgical resection was a significant factor for determining the recurrence of tumors (p = 0.0104). There was no significant effect of patients’ age, gender, tumor location, grade of differentiation, histological tumor type, and the size and depth of tumor invasion on the recurrence of the tumor. The recurrence rate was significantly higher in the low CD105-MVD group of patients than in the high CD105-MVD group of patients (log rank test, p = 0.0406). Result of the multivariate analysis showed that the type of surgery (p = 0.0086), MVD tumors (p = 0.0385), and MVD of proximal resection margin (p = 0.0218) were the independent prognostic factors for the recurrent tumors.

Conclusions

CD105-assessed MVD could help to identify patients with more aggressive disease and increased risk of developing tumor recurrence after surgical treatment in stage II rectal cancer (RC).