Experience of surgery for rectal cancer with total mesorectal excision in a general surgical practice

Image-guided high-dose-rate interstitial brachytherapy for recurrent rectal cancer after salvage surgery: a case report

Treatment options for patients with recurrent rectal cancer in pelvis represent a significant challenge because the balance of efficiency and toxicity needs to be pursued. This case report illustrates a treatment effect of image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for locally relapsed rectal cancer after salvage surgery. A 61-year-old male who underwent laparoscopic high anterior resection (LAP-HAR) with D3 lymph node dissection as a primary treatment for rectal cancer (pT3N0M0, well-differentiated adenocarcinoma) had relapsed locally 8 months after initial surgery, for which he underwent salvage abdominal perineal resection (APR), followed by adjuvant 8 cycles of XELOX (capecitabine and oxaliplatin) chemotherapy. He developed pelvic recurrence 1 year after the second surgery. Image-guided HDR-ISBT was performed (30 Gy/5 fractions/3 days) followed by external beam radiation therapy with 39.6 Gy in 22 fractions. There were no severe complications related to salvage radiotherapy. CEA was decreased from 24.5 ng/ml to 0.7 ng/ml, 4 months after the salvage radiotherapy. Complete response was noted on follow-up MRIs done on 2, 5, 8, and 14 months after the treatment. Hence, HDR-ISBT appears to be effective for locally recurrent rectal cancer even after salvage surgery.

Intraoperative blood loss during surgical treatment of low-rectal cancer by abdominosacral resection is higher than during extra-levator abdominosacral amputation of the rectum

INTRODUCTION

Abdominosacral resection (ASR) usually required blood transfusions, which are virtually no longer in use in the modified abdominosacral amputation of the rectum (ASAR). The aim of this study was to compare the intra-operative bleeding in low-rectal patients subjected to ASR or ASAR.

MATERIAL AND METHODS

The study included low-rectal cancer patients subjected to ASR (n = 114) or ASAR (n = 46) who were retrospectively compared in terms of: 1) the frequency of blood transfusions during surgery and up to 24 h thereafter; 2) the volume of intraoperative blood loss (ml of blood transfused) during surgery and up to 24 h thereafter; 3) hemoglobin concentrations (Hb) 1, 3 and 5 days after surgery; 4) the duration of hospitalization.

RESULTS

Blood transfusions were necessary in 107 ASR patients but in none of those subjected to ASAR (p < 0.001). Median blood loss in the ASR group was 800 ml (range: 100-4500 ml). The differences between the groups in median Hb determined 1, 3 and 5 days following surgery were insignificant. The proportions of patients with abnormal values of Hb, however, were significantly higher in the ASR group on postoperative days 1 and 3 (day 1: 71.9% vs. 19.6% in the ASAR group, p = 0.025; day 3: 57.% vs. 13.0%, p = 0.009). Average postoperative hospitalization in ASR patients was 13 days compared to 9 days in the ASAR group (p = 0.031).

CONCLUSIONS

Abdominosacral amputation of the rectum predominates over ASR in terms of the prevention of intra- and postoperative bleeding due to the properly defined surgical plane in low-rectal cancer patients.

Increased use of multidisciplinary treatment modalities adds little to the outcome of rectal cancer treated by optimal total mesorectal excision

PURPOSE

Total mesorectal excision (TME) is the standard surgical treatment for rectal cancer. The roles of chemotherapy and radiotherapy have become more defined, accompanied by improvements in preoperative staging and histopathological assessment. We analyse our ongoing results in the light of changing patterns of treatment over consecutive time periods.

METHODS

In total, 151 consecutive patients underwent potentially curative rectal excision for cancer in a single institution. Management and outcomes were compared between 1993-1999 and 2000-2007 which corresponded with the restructuring of the regional oncological services.

RESULTS

We found an increase in patients treated with neoadjuvant chemoradiotherapy after 1999 (20/89 vs 1/62, p < 0.001). There was an increase in the mean number of lymph nodes examined (11.9 vs 9.4, p = 0.037). The locoregional recurrence rate was 5.3%. The rates were not significantly different between the two study periods [4/89 (4.5%) 1999-2007 vs 4/62 (6.5%) 1993-1999, p = 0.597]. There was no statistical difference in overall or disease-free survival in the time periods examined.

CONCLUSIONS

Increasing use of neoadjuvant therapy and concomitant improvement in lymph node assessment did not translate into a concurrent reduction in the local recurrence, disease-free and overall survival rates. Our results demonstrate the enduring benefit of specialist training in TME in the outcome of rectal cancer surgery. This observational study suggests that low local recurrence rates are surrogate markers for improved overall and disease-free survival. Multidisciplinary team practice should be examined and made cost effective according to the individual unit's local recurrence rate in the light of this and other reports.

Current perioperative practice in rectal surgery in Austria and Germany

OBJECTIVE

'Fast-track' rehabilitation is able to accelerate recovery, reduce general morbidity, and decrease hospital stay. This is widely accepted for colonic resections. Despite recent evidence that fast track concepts are safe and feasible in rectal resection, there is no information on the acceptance and utilization of these concepts among Austrian and German surgeons.

METHOD

A questionnaire concerning perioperative routines in elective, open rectal resection was sent to the chief surgeons of 1,270 German and 120 Austrian surgical centers.

RESULTS

The response rate was 63% in Austria (76 centers) and 30% in Germany (385 centers). Mechanical bowel preparation is only abandoned by 2% of the Germany and 7% of the Austrian surgeons. Nasogastric decompression tubes are rarely used; four of five of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centers allow the intake of clear fluids on the day of surgery. Mobilization starts in half of the centers on the day of surgery. Epidural analgesia is used in three-fourths of the institutions. Institutions which have implemented fast track rehabilitation for rectal resections discharge the patients earlier then hospitals that adhere to traditional care.

CONCLUSION

In many perioperative procedures, Austrian and German Surgeons rely on their traditional approaches. Recent evidence-based adaptations of perioperative routines in rectal resections are only slowly introduced into daily routine; therefore, further efforts have to be done to optimizing patients' care.

Mortality risk analysis following routine vs selective defunctioning stoma formation after total mesorectal excision for rectal cancer

OBJECTIVE

To answer the question whether a defunctioning stoma (DS) should be constructed routinely after total mesorectal excision or whether it could be used selectively to ensure patient safety.

METHOD

A PubMed search was performed. All randomized trials on the role of a DS were included. Also, observational articles published between January 1997 and August 2007 were reviewed. Sensitivity analysis of the mortality risk was performed.

RESULTS

The clinical anastamotic leak (CAL) rate was 17% in 358 patients from four randomized trials and 9.6% in 4059 patients from 39 observational studies. The CAL rate increased significantly from 9.6% with DS to 24.4% without DS in four randomized trials, and from 7.9% with DS to 13.2% without DS in 17 observational studies. The re-operation rate as a result of anastomotic leakage was lower in patients with DS than in patients without DS in both study types. Leak-related mortality was not significantly different: 7.2% with vs 7.7% without DS in observational studies, and 0% with vs 4.6% without DS in randomized trials. Sensitivity analysis indicated that a selective DS strategy is acceptable if the CAL rate without DS is less than 16.6% with a CAL-related mortality of no more than 4.6%.

CONCLUSION

The results of this review support the routine construction of a protective stoma. However, selective use of a DS is justified from a patient safety point of view if the CAL-rate and its related mortality are limited. Each unit should audit its performance.

"Fast-track" rehabilitation after rectal cancer resection

BACKGROUND AND AIMS

After rectal cancer surgery, postoperative general complications occur in 25-35% of all patients and postoperative hospital stay is 14-21 days. "Fast-track" rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Because the feasibility of "fast-track" rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we demonstrate our initial results of "fast-track" rectal cancer surgery.

PATIENTS AND METHODS

Seventy consecutive unselected patients undergoing rectal cancer resection by one surgeon underwent a perioperative "fast-track" rehabilitation. Demographic and operative data, pulmonary function, pain and fatigue, local and general complications and mortality were assessed prospectively.

RESULTS AND FINDINGS

Thirty-six female and 34 male patients aged 65 (34-77) years underwent open (n=31) or laparoscopic (n=39) anterior resection with partial mesorectal excision (PME 27), anterior resection with total mesorectal excision and protective loop ileostomy (TME 29) or abdominoperineal excision with colostomy (APR 14). Overall, pulmonary function returned to >80% of preoperative value on day 2 (1-4) and the first bowel movement occurred on day 1 (0-3) after surgery. The incidence of local and general complications was 27 and 18%, respectively. Postoperative hospital stay was 8 (3-50) days overall, but shorter after PME [5 (3-47)] than TME [10 (5-42)] or APR [9 (5-50)] (p<0.01).

INTERPRETATION AND CONCLUSION

"Fast-track" rehabilitation was feasible in patients undergoing rectal cancer resection. Local morbidity was not increased, while general morbidity and postoperative hospital stay compared favourably to other series with "traditional" perioperative care.

Rectal cancer: from outcomes of care to process of care

This paper represents a current opinion on the impact surgeons may have on the variability of the quality of care of rectal cancer surgery. No systematic review of the evidence available in the literature is provided. The objective is to present a concise insight on selected outcomes of care studies, to review the limitations of such studies and to discuss the value of process of care studies. Outcomes of care studies measure what happens to patients, and process of care studies measure what is done to patients. Three variables are reviewed: training, volume and individual skill. It is concluded that the quality of the selected outcomes of care studies is not sufficient to draw definitive conclusions on whether surgeons are a variable. Further efforts should prompt process of care studies on rectal cancer surgery. This implies that outcomes should be measured, processes of care modified and outcomes measured again. This cycle should be continuously repeated in order to achieve the best quality of care.

Nationwide quality assurance of rectal cancer treatment

OBJECTIVE

The purpose of this prospective study was to examine the influence of the efforts for nationwide quality assurance of rectal cancer treatment. The study focuses on local recurrence and overall survival.

METHODS

This study includes all 3388 Norwegian patients with a rectal cancer within 15 cm from the anal verge treated with curative intent in the period November 1993-December 1999. A comprehensive educational programme was established, and training courses were arranged in different Health Regions demonstrating the TME technique. A specific Rectal Cancer Registry enabled the monitoring of outcome of rectal cancer treatment for single hospitals. Radiotherapy was given to 10% of the patients.

RESULTS

The risk of local recurrence has been significantly reduced, so that in 1999 the level was 50% below that observed in 1994 (Hazard ratio (HR)1999=0.5; 95% CI 0.4-0.8, P=0.002). Similarly, during 1998, the mean national overall survival was significantly improved, compared to the rate in 1994 (HR1998=0.8; 95% CI 0.6-1.0, P=0.014).

CONCLUSION

The prognosis for rectal cancer can be improved by increased organizational focus on rectal cancer treatment and by establishing a rectal cancer registry monitoring treatment standards throughout the country.

Changes in outcome following surgery for colorectal cancer: one surgeon’s experience

BACKGROUND

Colorectal cancer (CRC) has the second highest mortality rate of all cancers in Ireland. Developments in imaging, surgical technique, and perioperative care in the last two decades have altered management.

AIMS

To determine whether outcome following surgery for CRC in the mid-west has changed over a 22-year period.

METHODS

Four hundred and twenty-two patients were divided into two time periods: Group A (1980-1991, n = 203) and Group B (1992-2002, n = 219) and demographic, inpatient, and survival data were reviewed.

RESULTS

The mean age was 67 years, 59% were male. Group B patients had less advanced disease at presentation (Dukes' stage D 14% vs 22%, p < 0.05), fewer perioperative complications (13% vs 23%, p < 0.05), and fewer local recurrences (6.8% vs 11.8%, p < 0.05) than Group A. No difference in 30-day mortality rate or survival was detected.

CONCLUSIONS

Although perioperative CRC management has improved, methods of earlier diagnosis and improvements in adjuvant therapy should be explored to improve survival.

Surgeon and hospital volume and the management of colorectal cancer patients in Australia

BACKGROUND

The evidence for a relationship between patient outcomes and clinician and hospital volume is increasing. The National Colorectal Cancer Care Survey was undertaken to determine the management patterns in Australia for individuals newly diagnosed with colorectal cancer in a 3 month period in the year 2000.

METHODS

All new cases of colorectal cancer registered at each Australian State Cancer Registry were entered into the survey. This generated a questionnaire that was sent to the treating surgeon. Chi-squared tests and logistic regression analyses were used to determine levels of statistical significance.

RESULTS

Of 2,383 surgical questionnaires generated, 2,015 (85%) were completed. The majority (58%) of surgeons treated one or two patients with colorectal cancer over the 3 months of the survey. There was variation across surgeon cohorts for preoperative measures including the use of deep vein thrombosis prophylaxis. Patients seen by low volume surgeons were most likely to be given a permanent stoma (P < 0.0001). Patients with rectal cancer who were operated on by high volume surgeons were significantly more likely to receive a colonic pouch (P < 0.0001).

CONCLUSION

This nationwide population-based survey of the treatment of colorectal cancer patients suggests that the delivery of care by surgeons (the majority) who treat patients with rectal cancer infrequently should be evaluated.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level

Background

The purpose of this prospective study was to examine the influence of hospital caseload on long-term outcome following standardization of rectal cancer surgery at a national level.

Methods

Data relating to all 3388 Norwegian patients with rectal cancer treated for cure between November 1993 and December 1999 were recorded in a national database. Treating hospitals were divided into four groups according to their annual caseload: hospitals in group 1 (n = 4) carried out 30 or more procedures, those in group 2 (n = 6) performed 20–29 procedures, group 3 (n = 16) 10–19 procedures and group 4 (n = 28) fewer than ten procedures.

Results

The 5-year local recurrence rates were 9·2, 14·7, 12·5 and 17·5 per cent (P = 0·003) and 5-year overall survival rates were 64·4, 64·0, 60·8 and 57·8 per cent (P = 0·105) respectively in the four hospital caseload groups. An annual hospital caseload of less than ten procedures increased the risk of local recurrence compared with that in hospitals where 30 or more procedures were performed each year (hazard ratio 1·9 (95 per cent confidence interval (c.i.) 1·3 to 2·7); P &lt; 0·001). Overall survival was lower for patients treated at hospitals with an annual caseload of less than ten versus hospitals with 30 or more (hazard ratio 1·2 (95 per cent c.i. 1·0 to 1·5); P = 0·023).

Conclusion

The rate of local recurrence was higher for hospitals with a low annual caseload of less than ten procedures than for hospitals with a high treatment volume of 30 or more. Patients treated in small hospitals also had a shorter long-term survival than those treated in large hospitals.

Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery

OBJECTIVES

A recent study showed less bleeding and need of transfusion after total mesorectal excision (TME) compared with conventional rectal cancer surgery. The aim of this study was to evaluate this result in more details.

PATIENTS AND METHODS

Comparison of transfusion history in rectal cancer resections in two different multicentre-studies. Two hundred and forty-six patients were operated in the period 1991-93 with a conventional technique and 311 patients were operated with TME-technique in the period 1996-98. Peri-operative data, including blood transfusion from one month before until one month after the operation, was recorded prospectively.

RESULTS

The median intra-operative blood loss was 1000 ml, range 50-6000 ml, before, and 550 ml, range 10-6000 ml (P < 0.001) after introduction of TME. The overall peri-operative transfusion rate was reduced from 73% to 43% (P < 0.001). When adjusted for blood loss, age, gender, weight, and type of resection, TME significantly reduced the risk of receiving intra or postoperative blood transfusion by 0.4 (CI: 0.3-0.6). The variability in blood loss among 12 TME-centres was more than 400% and not correlated with transfusion requirements within the centres.

CONCLUSION

TME results in a reduced blood loss and a reduction of blood transfusion, but additional factors others than blood loss seems to influence the decision of transfusion.

[Surgical therapy of rectal carcinoma]

Total mesorectal excision (TME) has gained a revolutionary impact on the surgical therapy of rectal cancer within the last 2 decades, providing superior local tumor control in comparison to conventional resection. Consequently, 85% of rectal carcinomas can be resected by sphincter-preserving surgery without compromising either oncologic radicality or continence. With the introduction of TME, local recurrence rates have been reliably decreased below 10% after curative resection. Surgical dissection along the connective tissue space between rectal and parietal pelvic fascia with complete mesorectal excision results in reliable excision of all relevant lymphatic pathways with preservation of continence and sexual function. Complete removal of a TME specimen is mandatory in carcinomas of the middle and lower third of the rectum. Both removal of the complete TME specimen and careful pathologic examination of the circumferential resection margin have decisive significance. An additional pelvic lymphadenectomy with the potential risk of increased morbidity does not improve prognosis. As a spread of tumor distally along the bowel wall rarely exceeds a few centimeters, a distal resection margin of 1-2 cm is oncologically sufficient in sphincter-saving procedures without compromising prognosis. Taken together, the convincing results of TME provide a rationale for using TME as the dissection policy of choice to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from prospective randomized trials. The question whether laparoscopic curative resection for rectal cancer is oncologically adequate cannot be definitely answered to date, as results of randomized studies are currently missing. However, the preliminary results of laparoscopic resection for rectal cancer provided by centers are promising.

Rectal cancer. Is the surgeon the variable in the outcome?

Four factors influence the outcome of rectal surgery: tumour biology, stage of lesion, type of surgery performed and the performing surgeon himself. Tumour biology and tumour stage depend on each other and are not influenced on by the surgeon, while he seems to have a great influence on the latter two factors. This influence mainly consists of the following: training, volume, individual skill and experience.

CT-fluoroscopy guided interstitial brachytherapy with image-based treatment planning for unresectable locally recurrent rectal carcinoma

PURPOSE

The aim of the study is to develop high-dose-rate (HDR) conformal interstitial brachytherapy by means of combined CT-fluoroscopy guidance with CT-based treatment planning for locally recurrent rectal carcinoma.

METHODS AND MATERIALS

Brachytherapy needle insertion was guided with a helical CT scanner providing continuous fluoroscopy reconstruction. A video monitor placed adjacent to the CT gantry simultaneously allowed the operator to see the process of needle insertion. Final CT images were transferred by an online system to the treatment-planning computer, which reconstructed the implant needles and organ contours. The doses in planning target volume were normalized and geometrically optimized. The patients received a brachytherapy dose at 5 Gy twice daily with a hypofractionated accelerated schedule at a total dose of 30-50 Gy with or without external radiation therapy. Eighteen patients were treated with this procedure.

RESULTS

Ten to thirty-six needles (average, 17.3) were successfully placed to the planning target volume in each patient. The average time for CT fluoroscopy was 357 seconds for each procedure. No accident was seen at needle insertion, but 2 patients developed incomplete peroneal nerve palsy after needle removal, but gradually recovered. CT-based treatment planning was faster and more accurate than projection reconstruction with conventional radiograms. Analysis of the dose volume histogram showed conformal dose distribution to the target, while avoiding normal structures.

CONCLUSION

CT fluoroscopy guidance ensures safety and increases the accuracy of needle placement in brachytherapy. Conformal high-dose-rate (HDR) interstitial brachytherapy with CT-based treatment planning is a method worth considering for locally recurrent rectal cancer.

Options for sphincter preservation in surgery for low rectal cancer

BACKGROUND

Abdominoperineal excision of the rectum with a permanent end-sigmoid colostomy was the classical operation for cancer of the distal third of the rectum. A number of factors have recently led to a more conservative approach, allowing sphincter preservation when excising tumours that are not invading the anal sphincter.

METHODS

The review is based on the published literature of the treatment of low rectal cancers accessed by searching Medline and other online databases. It includes a description of all the surgical options currently available for low rectal tumours, and a discussion of the advantages and disadvantages of the types of anastomosis and reconstruction.

RESULTS AND CONCLUSION

It is now technically possible to remove rectal cancer that is extending into the anal canal with preservation of the anal sphincter mechanism and with a satisfactory oncological outcome. Ultra-low colorectal and coloanal anastomosis, together with a colonic pouch or coloplasty, produces acceptable function in many patients. However, there is still controversy about the risk of tumour implantation, the place of downsizing neoadjuvant therapy, and true long-term functional outcome. Despite these concerns, surgeons should strive to perform rectal resection with sphincter preservation for low-lying rectal cancer whenever possible.