Sphincter-saving operations for cancer of the rectum

Quality of life meta-analysis following coloanal anastomosis versus abdominoperineal resection for low rectal cancer

AIM

In low rectal cancers without sphincter involvement a permanent stoma can be avoided without compromising oncological safety. Functional outcomes following coloanal anastomosis (CAA) compared to abdominoperineal excision (APR) may be significantly different. This study examines all available comparative quality of life (QoL) data for patients undergoing CAA versus APR for low rectal cancer.

METHODS

Published studies with comparative data on QoL outcomes following CAA versus APR for low rectal cancer were extracted from electronic databases. The study was registered with PROSPERO and adhered to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data was combined using random-effects models.

RESULTS

Seven comparative series examined QoL in 527 patients. There was no difference in the numbers receiving neoadjuvant radiotherapy in the APR and CAA groups (OR: 1.19, 95% CI: 0.78-1.81, p = 0.43). CAA was associated with higher mean scores for physical functioning(std mean diff -7.08, 95% CI: -11.92 to -2.25, p = 0.004) and body image (std. mean diff 11.11, 95% CI: 6.04-16.18, p < 0.0001). Male sexual problems were significantly increased in patients who had undergone APR compared to CAA (std. mean diff -16.20, 95% CI: -25.76 to -6.64, p = 0.0009). Patients who had an APR reported more fatigue, dyspnoea and appetite loss. Those who had a CAA reported higher scores for both constipation and diarrhoea.

DISCUSSION

It is reasonable to offer a CAA to motivated patients where oncological outcomes will not be threatened. QoL outcomes appear to be superior when intestinal continuity is maintained, and permanent stoma avoided.

Image-guided resection of aggressive sacral tumors

OBJECTIVE The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors. METHODS The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type. RESULTS Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type. CONCLUSIONS Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

Sphincter-saving surgeries for rectal cancer: A single center study from Kashmir

Summary and Background Data:

The goals in the treatment of rectal cancer are cure, local control, and preservation of sphincter, bladder and sexual function. Surgical resection using sharp mesorectal dissection is important for achieving these goals.

Objectives:

The current treatment of choice for carcinoma rectum is sphincter saving procedures, which have practically replaced the previously done abdominoperineal resection. We performed a study in our institute to evaluate the surgical outcome and complications of rectal cancer.

Materials and Methods:

This prospectivestudy included 117 patients, treated for primary rectal cancer by low anterior resection (LAR) from May 2007 to December 2010. All patients underwent standard total mesorectal excision (TME) followed by restoration of continuity.

Results:

The peri-operative mortality rate was 2.5% (3/117). Post-operative complications occurred in 32% of the patients. After a median follow up of 42 months, local recurrences developed in 6 (5%) patients and distant metastasis in 5 (4.2%). The survival rate was 93%.

Conclusion:

The concept of total mesorectal excision (TME), advances in stapling technology and neoadjuvant therapy have made it possible to preserve the anal sphincter in most of the patients. Rectal cancer needs to be managed especially in a specialized unit for better results.

Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule

OBJECTIVE

To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge.

SUMMARY BACKGROUND DATA

Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection.

METHODS

From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy.

RESULTS

Ninety-two patients with a tumor at 3 (range 1.5-4.5) cm from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2% and the 5-year overall and disease-free survival were 81% and 70%, respectively.

CONCLUSIONS

The technique of intersphincteric resection permits us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. Tumor distance from the anal verge is no longer a limit for sphincter-saving resection.

Anastomotic integrity and function: role of the colonic J-pouch

Since the colonic J-pouch with a colo-anal anastomosis was first introduced in 1986, many reports have shown the superiority of this design as compared to a "straight" colo-anal anastomosis. These advantages have been demonstrated in retrospective, prospective, and prospectively randomized reports. Furthermore, these attributes are realized for at least 12 and possibly more than 24 months after surgery.

Functional and oncologic results after coloanal anastomosis for low rectal carcinoma

Thirty-five patients who had adenocarcinoma of the middle third of the rectum were treated by resection and coloanal anastomosis. The aim of this study was to assess functional and oncologic results of an original technique of coloanal anastomosis. There was no operative mortality, and operative morbidity consisted of seven anastomotic leaks with two failures. Among 31 patients assessed for functional results only one had unsatisfactory results. Good continence was obtained within a few weeks for the 30 patients who had satisfactory results. No patients were lost to follow-up, which was over 5 years in 24 patients (68%). The 5-year survival rate was 64%, identical to that for other series.

Rectal lymphoscintigraphy

Regional lymph nodes of the rectum are not demonstrable by pedal lymphoscintigraphy. We have evaluated the technique of rectal lymphoscintigraphy, using a technique similar to that which has been used in the assessment of lymph nodes in breast and prostatic cancer. Thirty-five patients were studied: ten normal subjects and 25 patients with rectal cancer. In normal subjects, the lymph nodes accompanying the superior hemorrhoidal artery and the inferior mesenteric artery are demonstrable in succession; after three hours the aortic lymph nodes are demonstrable. The 25 patients with rectal cancer underwent resection of their primary tumor and the stage was defined according to Dukes (1932). In five patients (stage A) no alteration was demonstrable. In 11 patients (stage B) the demonstration of regional lymph nodes was delayed vs. the control group. In nine cases (stage C) the demonstration of regional lymph nodes was delayed and defective versus the control group.

EEA stapler for mid-rectum carcinoma. Review of recent literature and own initial experience

Over a three-year period, 1980-82, 79 per cent of our patients with rectal cancer were treated with the intention of cure, and sphincter-saving procedures were performed in 62 per cent of these cases. This report concerns 21 patients with mid-rectum cancer operated on with low anterior resection and extraperitoneal EEA-stapled anastomosis. Nine patients had Dukes' stage A tumors, seven had stage B, and five had stage C tumors. An 86-year-old woman died in the sixth postoperative week, and a 74-year-old man died after 20 months with a probable recurrence. Nineteen patients are currently alive 4 to 40 months post-operatively, with no overt signs of recurrence. We cannot confirm recent alarming reports on a significant incidence of early local recurrence. Routine Gastrografin enemas were performed and offered very little in terms of clinical guidance. Significant anastomotic leakage occurred in four patients, although without clinical symptoms or the need for fecal diversion. Despite initially intact anastomoses in 13 patients, pelvic sepsis with late dehiscence developed in three, all of whom required fecal diversion. The clinical leak rate was thus 3 of 21, 14 per cent, and the total incidence of leakage 7 of 21, 33 per cent. We performed routine colostomy on the first three patients but, in retrospect, believe this was unneccessary. Only one of the 19 survivors still has a colostomy, due to a benign anastomotic stricture. We consider anterior resection of mid-rectum carcinoma with EEA-stapled anastomosis a highly feasible procedure, the curative potential of which, however, can be established only by long-term follow-up studies.

Observer variation in the histological grading of rectal carcinoma

The variation between two observers in grading 100 biopsies and the corresponding main specimens of rectal carcinomas has been examined. Using kappa statistics, which take account of chance agreement, we found a highly significant level of agreement. As expected, higher levels were obtained for intraobserver agreement. However, disagreements between observers were in many instances "haphazard" and there were differences in bias between them. Fifty paired biopsies and main tumours were graded by five observers and the results analysed for bias and by kappa statistics for overall and conditional agreement. These methods revealed significant overall agreement but the levels for some observer pairs did not differ significantly from chance. Examination for observer bias indicated differing standards of grading, and haphazard disagreements reached high levels for some observer pairs. The intraobserver agreement between the grade of the biopsy and the corresponding main tumour varied from 56-69% but only 52% of the poorly differentiated tumours were diagnosed as such in the preoperative biopsy by the "specialist" observer. The poor predictive value was not improved by taking multiple biopsies. We conclude that the grade of a rectal carcinoma cannot be accurately assessed on a preoperative biopsy and that this has serious implications for the management of low rectal cancers. Furthermore the wide discrepancies in diagnostic standards between some pathologists mean that studies on the treatment and prognosis of rectal cancer which utilise histological grade for comparison purposes must be viewed with considerable skepticism.

[Anterior resection and abdomino-perineal extirpation in patients with rectal cancer: a retrospective analysis (author's transl)]

Eighty-seven patients with an abdomino-perineal extirpation of the rectum and 75 patients with an anterior resection of the rectum could be analysed retrospectively. The mean observation period was 36 months for anterior resection and 38 months for abdomino-perineal extirpation. The rate of recurrences, mortality, and postoperative complications of each surgical method was correlated to tumor-localization, -staging, and -grading. The poor prognosis of patients with abdomino-perineal extirpation was mainly due to relatively more cases in advanced tumor stage. In rectal cancer above 7 cm anterior resection should be performed.

Excision of mid-rectal lesions by the Kraske sacral approach

Thirteen patients had a benign and 4 patients a malignant growth of the mid-rectum excised by the Kraske sacral procedure. Two patients developed a faecal fistula, one of which closed spontaneously. Recurrence of a villous adenoma occurred in 2 patients. There was no operative mortality and no thromboembolic or cardiovascular complications.