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Bolshinsky V, Sweet DE, Vitello DJ, Jia X, Holubar SD, Church J, Herts BR, Steele SR. Using CT-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery. Dis Colon Rectum 2024; 67:929-939. [PMID: 38517090 DOI: 10.1097/dcr.0000000000003147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND A complete total mesorectal excision is the criterion standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively the difficulty of proctectomy is largely unexplored. OBJECTIVE To determine pelvic structural factors associated with incomplete total mesorectal excision after curative proctectomy and build a predictive model for total mesorectal excision quality. DESIGN Retrospective cohort study. SETTING A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017). PATIENTS Curative-intent proctectomy for rectal adenocarcinoma. INTERVENTIONS All radiological measurements were obtained from preoperative CT images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports. MAIN OUTCOME MEASURES Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality. RESULTS Of the 410 cases meeting inclusion criteria, 362 underwent a complete total mesorectal excision (88%). Multivariable regression identified a deeper sacral curve (per 100 mm 2 [OR: 1.14; 95% CI, 1.06-1.23; p < 0.001]) and a greater transverse distance of the pelvic outlet (per 10 mm [OR:1.41, 95% CI, 1.08-1.84; p = 0.012]) to be independently associated with incomplete total mesorectal excision. An increased area of the pelvic inlet (per 10 cm 2 [OR: 0.85; 95% CI, 0.75-0.97; p = 0.02) was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs <0.4) between BMI (<30 vs ≥30) and sex was identified. A model was built to predict mesorectal quality using the following variables: depth of sacral curve, area of pelvic inlet, and transverse distance of the pelvic outlet. LIMITATIONS Retrospective analysis is not controlled for the choice of surgical approach. CONCLUSIONS Pelvimetry predicts total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in the comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract . USO DE MEDICIONES DE PELVIMETRA Y OBESIDAD VISCERAL BASADAS EN TC PARA PREDECIR LA CALIDAD DE TME EN PACIENTES SOMETIDOS A CIRUGA DE CNCER DE RECTO ANTECEDENTES:Una escisión mesorrectal total y completa es el estándar de oro en la cirugía curativa del cáncer de recto. Garantizar la calidad es un desafío en una pelvis estrecha y la obesidad amplifica las dificultades técnicas. La pelvimetría es la medición de las dimensiones pélvicas, pero su papel para medir la dificultad preoperatoria de la proctectomía está en gran medida inexplorado.OBJETIVO:Determinar los factores estructurales pélvicos asociados con la escisión mesorrectal total incompleta después de una proctectomía curativa y construir un modelo predictivo para la calidad de la escisión mesorrectal total.DISEÑO:Estudio de cohorte retrospectivo.ÁMBITO:Base de datos de un centro de referencia cuaternario de pacientes diagnosticados con adenocarcinoma de recto (2009-2017).PACIENTES:Proctectomía con intención curativa para adenocarcinoma de recto.INTERVENCIONES:Todas las mediciones radiológicas se obtuvieron a partir de imágenes de TC preoperatorias utilizando herramientas de software de procesamiento de imágenes validadas. La integridad de la escisión mesorrectal total se obtuvo a partir de informes histológicos.PRINCIPALES MEDIDAS DE VALORACIÓN:Capacidad de la pelvimetría radiológica y las mediciones de obesidad para predecir la calidad total de la escisión mesorrectal.RESULTADOS:De los 410 casos que cumplieron los criterios de inclusión, 362 tuvieron una escisión mesorrectal total completa (88%). Una regresión multivariable identificó una curva sacra más profunda (por 100 mm2); OR:1,14,[IC95%:1,06-1,23,p<0,001], y mayor distancia transversal de salida pélvica (por 10mm); OR:1,41, [IC 95%:1,08-1,84,p=0,012] como asociación independiente con escisión mesorrectal total incompleta. Un área aumentada de entrada pélvica (por 10 cm2); OR:0,85, [IC95%:0,75-0,97,p=0,02] se asoció con una mayor tasa de escisión mesorrectal completa. No se identificaron diferencias en la proporción de obesidad visceral y la obesidad visceral (proporción>0,4 vs.<0,4) entre el índice de masa corporal (<30 vs.>=30) o el sexo. Se construyó un modelo para predecir la calidad mesorrectal utilizando variables: profundidad de la curva sacra, área de la entrada pélvica y distancia transversal de la salida pélvica.LIMITACIONES:Análisis retrospectivo no controlado por la elección del abordaje quirúrgico.CONCLUSIONES:La pelvimetría predice la calidad de la escisión mesorrectal total en la cirugía del cáncer de recto y puede alertar a los cirujanos preoperatoriamente sobre casos de dificultad inusual. Este modelo predictivo puede contribuir a la estrategia de tratamiento y ayudar en la comparación de resultados entre técnicas tradicionales y novedosas de escisión mesorrectal total. (Traducción- Dr. Ingrid Melo).
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Affiliation(s)
| | - David E Sweet
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominic J Vitello
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xue Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - James Church
- Department of Colorectal Surgery, Columbia University Medical Center, Herbert Irving Pavilion, New York, New York
| | - Brian R Herts
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Andric M, Stockheim J, Rahimli M, Al-Madhi S, Acciuffi S, Dölling M, Croner RS, Perrakis A. Influence of Certification Program on Treatment Quality and Survival for Rectal Cancer Patients in Germany: Results of 13 Certified Centers in Collaboration with AN Institute. Cancers (Basel) 2024; 16:1496. [PMID: 38672577 PMCID: PMC11047918 DOI: 10.3390/cancers16081496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/18/2024] [Accepted: 03/23/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION The certification of oncological units as colorectal cancer centers (CrCCs) has been proposed to standardize oncological treatment and improve the outcomes for patients with colorectal cancer (CRC). The proportion of patients with CRC in Germany that are treated by a certified center is around 53%. Lately, the effect of certification on the treatment outcomes has been critically discussed. AIM Our aim was to investigate the treatment outcomes in patients with rectal carcinoma at certified CrCCs, in German hospitals of different medical care levels. METHODS We performed a retrospective analysis of a prospective, multicentric database (AN Institute) of adult patients who underwent surgery for rectal carcinoma between 2002 and 2016. We included 563 patients from 13 hospitals of different medical care levels (basic, priority, and maximal care) over periods of 5 years before and after certification. RESULTS The certified CrCCs showed a significant increase in the use of laparoscopic approach for rectal cancer surgery (5% vs. 55%, p < 0.001). However, we observed a significantly prolonged mean duration of surgery in certified CrCCs (161 Min. vs. 192 Min., p < 0.001). The overall morbidity did not improve (32% vs. 38%, p = 0.174), but the appearance of postoperative stool fistulas decreased significantly in certified CrCCs (2% vs. 0%, p = 0.036). Concerning the overall in-hospital mortality, we registered a positive trend in certified centers during the five-year period after the certification (5% vs. 3%, p = 0.190). The length of preoperative hospitalization (preop. LOS) was shortened significantly (4.71 vs. 4.13 days, p < 0.001), while the overall length of in-hospital stays was also shorter in certified CrCCs (20.32 vs. 19.54 days, p = 0.065). We registered a clear advantage in detailed, high-quality histopathological examinations regarding the N, L, V, and M.E.R.C.U.R.Y. statuses. In the performed subgroup analysis, a significantly longer overall survival after certification was registered for maximal medical care units (p = 0.029) and in patients with UICC stage IV disease (p = 0.041). In patients with UICC stage III disease, we registered a slightly non-significant improvement in the disease-free survival (UICC III: p = 0.050). CONCLUSIONS The results of the present study indicate an improvement in terms of the treatment quality and outcomes in certified CrCCs, which is enforced by certification-specific aspects such as a more differentiated surgical approach, a lower rate of certain postoperative complications, and a multidisciplinary approach. Further prospective clinical trials are necessary to investigate the influence of certification in the treatment of CRC patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (M.A.); (J.S.); (M.R.); (S.A.-M.); (S.A.); (M.D.); (R.S.C.)
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Lynch P, Ryan OK, Donnelly M, Ryan ÉJ, Davey MG, Reynolds IS, Creavin B, Hanly A, Kennelly R, Martin ST, Winter DC. Comparing neoadjuvant therapy followed by local excision to total mesorectal excision in the treatment of early stage rectal cancer: a systematic review and meta-analysis of randomised clinical trials. Int J Colorectal Dis 2023; 38:263. [PMID: 37924372 DOI: 10.1007/s00384-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME. METHODS A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes. RESULTS A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5-3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001). CONCLUSION NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.
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Affiliation(s)
- Paul Lynch
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Odhrán K Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Mark Donnelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éanna J Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Matthew G Davey
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Arquillière J, Dubois A, Rullier E, Rouanet P, Denost Q, Celerier B, Pezet D, Passot G, Aboukassem A, Colombo PE, Mourregot A, Carrere S, Vaudoyer D, Gourgou S, Gauthier L, Cotte E. Learning curve for robotic-assisted total mesorectal excision: a multicentre, prospective study. Colorectal Dis 2023; 25:1863-1877. [PMID: 37525421 DOI: 10.1111/codi.16695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/19/2023] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
AIM Robotic-assisted surgery (RAS) is becoming increasingly important in colorectal surgery. Recognition of the short, safe learning curve (LC) could potentially improve implementation. We evaluated the extent and safety of the LC in robotic resection for rectal cancer. METHOD Consecutive rectal cancer resections (January 2018 to February 2021) were prospectively included from three French centres, involving nine surgeons. LC analyses only included surgeons who had performed more than 25 robotic rectal cancer surgeries. The primary endpoint was operating time LC and the secondary endpoint conversion rate LC. Interphase comparisons included demographic and intraoperative data, operating time, conversion rate, pathological specimen features and postoperative morbidity. RESULTS In 174 patients (69% men; mean age 62.6 years) the mean operating time was 334.5 ± 92.1 min. Operative procedures included low anterior resection (n = 143) and intersphincteric resection (n = 31). For operating time, there were two or three (centre-dependent) LC phases. After 12-21 cases (learning phase), there was a significant decrease in total operating time (all centres) and an increase in the number of harvested lymph nodes (two centres). For conversion rate, there were two or four LC phases. After 9-14 cases (learning phase), the conversion rate decreased significantly in two centres; in one centre, there was a nonsignificant decrease despite the treatment of significantly more obese patients and patients with previous abdominal surgery. There were no significant differences in interphase comparisons. CONCLUSION The LC for RAS in rectal cancer was achieved after 12-21 cases for the operating time and 9-14 cases for the conversion rate. RAS for rectal cancer was safe during this time, with no interphase differences in postoperative complications and circumferential resection margin.
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Affiliation(s)
- J Arquillière
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
| | - A Dubois
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - E Rullier
- Department of Digestive Surgery, Colorectal Unit, Bordeaux University Hospital, Haut-Lévèque Hospital, Pessac, France
| | - P Rouanet
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - Q Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - B Celerier
- Department of Digestive Surgery, Colorectal Unit, Bordeaux University Hospital, Haut-Lévèque Hospital, Pessac, France
| | - D Pezet
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - G Passot
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
| | - A Aboukassem
- Department of Colorectal Surgery, CHU Estaing, Clermont-Ferrand, France
| | - P E Colombo
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - A Mourregot
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - S Carrere
- Department of Colorectal Surgery, Institut Du Cancer De Montpellier, Montpellier, France
| | - D Vaudoyer
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - L Gauthier
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - E Cotte
- Department of Digestive and Oncological Surgery, Lyon University Hospital, Lyon-Sud Hospital, Pierre-Bénite, France
- Lyon Center for Innovation in Cancer, CICLY EA 3738, Lyon 1 University, Lyon, France
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Aslanov K, Atici AE, Karaman D, Bozkurtlar E, Yegen ŞC. Optimal waiting period to surgical treatment after neoadjuvant chemoradiotherapy for locally advanced rectum cancer: a retrospective observational study. Langenbecks Arch Surg 2023; 408:210. [PMID: 37227524 DOI: 10.1007/s00423-023-02930-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The optimal waiting period after neoadjuvant treatment in patients with locally advanced rectal cancers is still controversial. The literature has different results regarding the effect of waiting periods on clinical and oncological outcomes. We aimed to investigate the effects of these different waiting periods on clinical, pathological, and oncological outcomes. METHODS Between January 2014 and December 2018, a total of 139 consecutive patients with locally advanced rectal adenocarcinoma, who were treated in the Department of General Surgery at the Marmara University Pendik Training and Research Hospital, were enrolled in the study. The patients were split into three groups according to waiting time for surgery after neoadjuvant treatment: group 1 (n = 51) included patients that have 7 weeks and less (≤ 7 weeks) time interval, group 2 (n = 45) 8 to 10 weeks (8-10 weeks), group 3 (n = 43) 11 weeks and above (11 weeks ≤). Their database records, which were entered prospectively, were analyzed retrospectively. RESULTS There were 83 (59.7%) males and 56 (40.3%) females. The median age was 60 years, and there was no statistical difference between the groups regarding age, gender, BMI, ASA score, ECOG performance score, tumor location, and preoperative CEA values. Also, we found no significant differences regarding operation times, intraoperative bleeding, length of hospital stay, and postoperative complications. According to the Clavien-Dindo (CD) classification, severe early postoperative complications (CD 3 and above) were observed in 9 patients. The complete pathological response (pCR, ypT0N0) was observed in 21 (15.1%) patients. The groups had no significant difference regarding 3-year disease-free and 3-year overall survival (p = 0.3, p = 0.8, respectively). Local recurrence was observed in 12 of 139 (8.6%) patients and distant metastases occurred in 30 of 139 (21.5%) patients during the follow-up period. There was no significant difference between the groups in terms of both local recurrence and distant metastasis (p = 0.98, p = 0.43, respectively). CONCLUSION The optimal time for postoperative complications and sphincter-preserving surgery in patients with locally advanced rectal cancer is 8-10 weeks. The different waiting periods do not affect disease-free and overall survival. While long-term waiting time does not make a difference in pathological complete response rates, it negatively affects the TME quality rate.
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Affiliation(s)
- Khayal Aslanov
- Department of General Surgery, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Ali Emre Atici
- Department of General Surgery, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey.
| | - Damlanur Karaman
- Department of Pathology, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Emine Bozkurtlar
- Department of Pathology, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Şevket Cumhur Yegen
- Department of General Surgery, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
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Darwich I, Abuassi M, Aliyev R, Scheidt M, Alkadri MA, Hees A, Demirel-Darwich S, Chand M, Willeke F. Early experience with the ARTISENTIAL ® articulated instruments in laparoscopic low anterior resection with TME. Tech Coloproctol 2022; 26:373-386. [PMID: 35141794 PMCID: PMC9018813 DOI: 10.1007/s10151-022-02588-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/23/2022] [Indexed: 11/10/2022]
Abstract
Background The notion of articulation in surgery has been largely synonymous with robotics. The ARTISENTIAL® instruments aim at bringing advanced articulation to laparoscopy to overcome challenges in narrow anatomical spaces. In this paper, we present first single-center results of a series of low anterior resections, performed with ARTISENTIAL®. Methods Between September 2020 and August 2021, at the Department of Surgery, St. Marienkrankenhaus Siegen, Siegen, Germany, patients with cancer of the mid- and low rectum were prospectively enrolled in a pilot feasibility study to evaluate the ARTISENTIAL® articulated instruments in performing a laparoscopic low anterior resection. Perioperative and short-term postoperative data were analyzed. Results Seventeen patients (10 males/7 females) were enrolled in this study. The patients had a median age of 66 years (range 47–80 years) and a median body mass index of 28 kg/m2 (range 23–33 kg/m2). The median time to rectal transection was 155 min (range 118–280 min) and the median total operative time was 276 min (range 192–458 min). The median estimated blood loss was 30 ml (range 5–70 ml) and there were no conversions to laparotomy. The median number of harvested lymph nodes was 15 (range 12–28). Total mesorectal excision (TME) quality was ‘good’ in all patients with no cases of circumferential resection margin involvement (R0 = 100%). The median length of stay was 9 days (range 7–14 days). There were no anastomotic leaks and the overall complication rate was 17.6%. There was one unrelated readmission with no mortality. Conclusions Low anterior resection with ARTISENTIAL® is feasible and safe. All patients had a successful TME procedure with a good oncological outcome. We will now seek to evaluate the benefits of ARTISENTIAL® in comparison with standard laparoscopic instruments through a larger study. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02588-y.
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Affiliation(s)
- I Darwich
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany.
| | - M Abuassi
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - R Aliyev
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - M Scheidt
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - M A Alkadri
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - A Hees
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - S Demirel-Darwich
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
| | - M Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, 43-45 Foley Street, London, W1W 7JN, UK
| | - F Willeke
- Department of Surgery, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Germany
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Zhang S, Yu M, Chen D, Li P, Tang B, Li J. Role of MRI‑based radiomics in locally advanced rectal cancer (Review). Oncol Rep 2021; 47:34. [PMID: 34935061 PMCID: PMC8717123 DOI: 10.3892/or.2021.8245] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022] Open
Abstract
Colorectal cancer is the third most common type of cancer, with high morbidity and mortality rates. In particular, locally advanced rectal cancer (LARC) is difficult to treat and has a high recurrence rate. Neoadjuvant chemoradiotherapy (NCRT) is one of the standard treatment programs of LARC. If the response to treatment and prognosis in patients with LARC can be predicted, it will guide clinical decision‑making. Radiomics is characterized by the extraction of high‑dimensional quantitative features from medical imaging data, followed by data analysis and model construction, which can be used for tumor diagnosis, staging, prediction of treatment response and prognosis. In recent years, a number of studies have assessed the role of radiomics in NCRT for LARC. MRI‑based radiomics provides valuable data and is expected to become an imaging biomarker for predicting treatment response and prognosis. The potential of radiomics to guide personalized medicine is widely recognized; however, current limitations and challenges prevent its application to clinical decision‑making. The present review summarizes the applications, limitations and prospects of MRI‑based radiomics in LARC.
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Affiliation(s)
- Siyu Zhang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610041, P.R. China
| | - Mingrong Yu
- College of Physical Education, Sichuan Agricultural University, Ya'an, Sichuan 625000, P.R. China
| | - Dan Chen
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610041, P.R. China
| | - Peidong Li
- Second Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Bin Tang
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, Sichuan 610041, P.R. China
| | - Jie Li
- Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Radiation Oncology Key Laboratory of Sichuan Province, Chengdu, Sichuan 610041, P.R. China
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Javed MA, Shamim S, Slawik S, Andrews T, Montazeri A, Ahmed S. Long-term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer. Colorectal Dis 2021; 23:1953-1960. [PMID: 33900004 DOI: 10.1111/codi.15693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/24/2021] [Accepted: 03/23/2021] [Indexed: 12/11/2022]
Abstract
AIM Management of early rectal cancer following transanal microscopic anal surgery poses a management dilemma when the histopathology reveals poor prognostic features, due to high risk of local recurrence. The aim of this study is to evaluate the oncological outcomes of such patients who undergo surgery with total mesorectal excision (TME), receive adjuvant chemo/radiotherapy (CRDT/RT) or receive close surveillance only (no further treatment). METHODS We identified patients with poor prognostic factors-pT2 adenocarcinoma, poor differentiation, deep submucosal invasion (Kikuchi SM3), lymphovascular invasion, tumour budding or R1 resection margin-between 1 September 2012 and 31 January 2020 and report their oncological outcomes. RESULTS Of the 53 patients, 18 had TME, 14 had CRDT and 14 had RT; seven patients did not have any further treatment. The median follow-up was 48 months, 12 developed recurrence and six died. Overall, 5-year survival (OS) was 88.9% and disease-free survival (DFS) was 79.2%. Compared to the surgical group, in which there were eight recurrences and two deaths, there were zero recurrences or deaths in the CRDT group, log-rank test P = 0.206 for OS and P = 0.005 for DFS. The 5-year survival rates in the RT and surveillance only groups were OS 78.6%, DFS 85.7% and OS 71.5%, DFS 71% respectively. TME assessment in the surgical group revealed Grade 3 quality in seven of the 16 available reports. CONCLUSION These findings support the strategy of adjuvant CRDT as first line treatment for patients undergoing transanal endoscopic microsurgery for early rectal cancer with poor prognostic factors on initial histological assessment.
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Affiliation(s)
- Muhammad A Javed
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sarah Shamim
- Health Education England-North West, Manchester, UK
| | - Simone Slawik
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Timothy Andrews
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Amir Montazeri
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - Shakil Ahmed
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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9
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Longchamp G, Meyer J, Abbassi Z, Sleiman M, Toso C, Ris F, Buchs NC. Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence. Dig Dis 2020; 39:325-333. [PMID: 33011726 DOI: 10.1159/000511959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. SUMMARY After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.
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Affiliation(s)
- Gregoire Longchamp
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland,
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Ziad Abbassi
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Marwan Sleiman
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Frederic Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
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10
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Chang H, Tao YL, Jiang W, Chen C, Liu SL, Ye WJ, Gao YH. Optimize the dose of oxaliplatin for locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy followed by radical surgery and adjuvant chemotherapy. BMC Cancer 2020; 20:498. [PMID: 32487091 PMCID: PMC7268650 DOI: 10.1186/s12885-020-06988-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 05/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background Addition of oxaliplatin to capecitabine remains controversial for locally advanced rectal cancer (LARC). And cumulative oxaliplatin dose (COD) varied among clinical trials showing different therapeutic effects of this regimen. The objective of this study was to explore how COD affected tumor metastasis and patient survival. Methods Totally 388 patients diagnosed with stage cII-III rectal cancer and treated with neoadjuvant chemoradiotherapy followed by radical surgery plus adjuvant chemotherapy were consecutively enrolled into this study and retrospectively reviewed. After grouping by total chemotherapy cycle (TCC), influences of COD on adverse effects and patients’ survivals were analyzed in each group. Univariate and multivariate survival analyses were performed through Kaplan-Meier approach and COX proportional hazards model, respectively. Age, gender, anemia, differentiation, carcinoembryonic antigen, carbohydrate antigen 19–9, pretreatment clinical stage and postsurgical pathologic stage were used as covariates. Results COD < 460 mg/m2 emerged as an independent predictor of poorer overall, metastasis-free and disease-free survivals, in patients treated with TCC ≤ 7. The hazard ratios were 1.972, 1.763 and 1.637 (P values were 0.021, 0.028 and 0.041), respectively. But it was note-worthy that COD ≥460 mg/m2 increased incidence of acute toxicities from 38.4 to 70.8% (P < 0.001). And in patients treated with TCC ≥ 8, COD failed to be a prognosticator. Conclusions For LARC patients treated with insufficient TCC (≤ 7), oxaliplatin of ≥460 mg/m2 might be needed to improve survival, though it might resulted in more acute toxicities.
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Affiliation(s)
- Hui Chang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ya-Lan Tao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wu Jiang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chen Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shi-Liang Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wei-Jun Ye
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China. .,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
| | - Yuan-Hong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China. .,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
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11
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Lichthardt S, Wagner J, Löb S, Matthes N, Kastner C, Anger F, Germer CT, Wiegering A. Pathological complete response due to a prolonged time interval between preoperative chemoradiation and surgery in locally advanced rectal cancer: analysis from the German StuDoQ|Rectalcarcinoma registry. BMC Cancer 2020; 20:49. [PMID: 31959130 PMCID: PMC6971897 DOI: 10.1186/s12885-020-6538-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 01/13/2020] [Indexed: 12/27/2022] Open
Abstract
Background Preoperative chemoradiotherapy is the recommended standard of care for patients with local advanced rectal cancer. However, it remains unclear, whether a prolonged time interval to surgery results in an increased perioperative morbidity, reduced TME quality or better pathological response. Aim of this study was to determine the time interval for best pathological response and perioperative outcome compared to current recommended interval of 6 to 8 weeks. Methods This is a retrospective analysis of the German StuDoQ|Rectalcarcinoma registry. Patients were grouped for the time intervals of “less than 6 weeks”, “6 to 8 weeks”, “8 to 10 weeks” and “more than 10 weeks”. Primary endpoint was pathological response, secondary endpoint TME quality and complications according to Clavien-Dindo classification. Results Due to our inclusion criteria (preoperative chemoradiation, surgery in curative intention, M0), 1.809 of 9.560 patients were suitable for analysis. We observed a trend for increased rates of pathological complete response (pCR: ypT0ypN0) and pathological good response (pGR: ypT0-1ypN0) for groups with a prolonged time interval which was not significant. Ultimately, it led to a steady state of pCR (16.5%) and pGR (22.6%) in “8 to 10” and “more than 10” weeks. We were not able to observe any differences between the subgroups in perioperative morbidity, proportion of rectal extirpation (for cancer of the lower third) or difference in TME quality. Conclusion A prolonged time interval between neoadjuvant chemoradiation can be performed, as the rate of pCR seems to be increased without influencing perioperative morbidity.
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Affiliation(s)
- Sven Lichthardt
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Johanna Wagner
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Niels Matthes
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Caroline Kastner
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Friedrich Anger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany.,University of Wuerzburg, Comprehensive Cancer Center Mainfranken, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, Oberduerrbacherstr. 6, 97080, Wuerzburg, Germany. .,University of Wuerzburg, Comprehensive Cancer Center Mainfranken, Wuerzburg, Germany. .,Department of Biochemistry and Molecular Biology, Biocenter, University of Wuerzburg, Wuerzburg, Germany.
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12
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Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2019; 267:1034-1046. [PMID: 28984644 DOI: 10.1097/sla.0000000000002523] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery. SUMMARY OF BACKGROUND DATA Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data. METHODS We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods. RESULTS Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes. CONCLUSION Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.
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13
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Hu JM, Chu CH, Jiang JK, Lai YL, Huang IP, Cheng AYM, Yang SH, Chen CC. Robotic transanal total mesorectal excision assisted by laparoscopic transabdominal approach: A preliminary twenty-case series report. Asian J Surg 2019; 43:330-338. [PMID: 31320234 DOI: 10.1016/j.asjsur.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Laparoscopy-assisted robotic transanal total mesorectal excision is a novel surgical technique for rectal cancer resection. Compared to prior DaVinci Si system case series, this case series is the first to report robotic taTME assisted by laparoscopy (r-taTME) in which the "transanal team" operates via the DaVinci Xi system. As a result, we aim to delineate and discuss preliminary findings from our robotic taTME experiences. METHODS A total of twenty patients (twelve males) who underwent robotic taTME assisted by laparoscopy (r-taTME) between January 2016 and November 2016 at a single institution were documented. Surgical outcomes, including complications, pathological outcomes, and short-term results, were then retrospectively analyzed. RESULTS All patients underwent r-taTME via a two-team approach. The "abdominal team" operated via a single port method (ileostomy site), while the "transanal team" operated via the DaVinci Xi system. The mean patient age was 56.7 ± 14.3 years (range 31-79), and the mean distance from tumor to anal verge was 6.0 ± 2.7 cm (range 2-10). The mean estimated intraoperative blood loss was 88 ± 107 ml (range 30-500), and circular stapling was utilized to restore continuity in 80% of study patients. The overall postoperative complication rate was 35%, and the mean distal margin length was 3.1 ± 1.3 cm. There were three patients who had a circumferential margin (CRM) involved by cancer cells (≤1 mm). CONCLUSION Our preliminary series report demonstrates that utilization of r-taTME assisted by laparoscopy is safe and feasible. Development of a novel transanal approach that allows single-port access alongside a multi-arm robotic system may increase the convenience and efficiency of future operation.
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Affiliation(s)
- Je-Ming Hu
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Ho Chu
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeng-Kae Jiang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Andy Yi-Ming Cheng
- Department of Medicine, Division of Hospital Medicine, University of Pittsburgh Medical Center Shadyside Hospital, United States of America
| | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Hospital, Yilan, Taiwan
| | - Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan.
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14
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Li Z, Fu J, Du Z. Total mesoesophagus excision by thoracoscopy and laparoscopy in the radical resection of esophageal carcinoma. J Thorac Dis 2019; 11:3180-3182. [PMID: 31463147 PMCID: PMC6688023 DOI: 10.21037/jtd.2019.07.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 12/17/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Zhuoyi Li
- Department of Surgical Oncology, Shantou Central Hospital (Affiliated Shantou Hospital of Sun Yat-sen University), Shantou 515031, China
| | - Junhui Fu
- Department of Surgical Oncology, Shantou Central Hospital (Affiliated Shantou Hospital of Sun Yat-sen University), Shantou 515031, China
| | - Zesen Du
- Department of Surgical Oncology, Shantou Central Hospital (Affiliated Shantou Hospital of Sun Yat-sen University), Shantou 515031, China
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15
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Gao Y, Hu JL, Zhang XX, Zhang MS, Zheng XF, Liu SS, Lu Y. Accuracy of endoscopic ultrasound in rectal cancer and its use in transanal endoscopic microsurgery. MINIM INVASIV THER 2019; 29:90-97. [PMID: 30849259 DOI: 10.1080/13645706.2019.1585373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: This study evaluated the accuracy of endoscopic ultrasound (EUS) for preoperative staging of rectal cancer and guiding the treatment of transanal endoscopic microsurgery (TEM) in early rectal cancer.Material and methods: One-hundred-twenty-six patients with rectal cancer were staged preoperatively using EUS and the results were compared with postoperative histopathology results. Radical surgeries, including low anterior resection (LAR), abdominal-perineal resection (APR) and Hartmann surgeries, were performed on patients with advanced rectal cancers, and TEM was performed on patients with stage T1. The Kappa statistic was used to determine agreement between EUS-based staging and pathology staging.Results: The overall accuracies of EUS for T and N stage were 90.8% (Kappa = 0.709) and 76.7% (Kappa = 0.419), respectively. The accuracies of EUS for uT1, uT2, uT3, and uT4 stages were 96.8%, 92.1%, 84.1%, and 88.9%, respectively, and for uN0, uN1, and uN2 stages, they were 71.9%, 64.9%, and 93.0%, respectively. Twelve patients underwent TEM and received confirmed pathology results of early rectal cancer. After postoperative follow-up, there were no local recurrences or distant metastases.Conclusion: EUS is a good and comparable technique for postoperative staging of rectal cancer. Moreover, EUS is used as indicator for preoperative staging and tumor assessment strategy when considering TEM.
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Affiliation(s)
- Yuan Gao
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Ji-Lin Hu
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Xian-Xiang Zhang
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Mao-Shen Zhang
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Xue-Feng Zheng
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Shi-Song Liu
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China
| | - Yun Lu
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, PR China.,Shandong Key Laboratory of Digital Medicine and Computer Assisted Surgery, Qingdao University, Qingdao, PR China
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16
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Daly MC, Jung AD, Hanseman DJ, Shah SA, Paquette IM. Surviving rectal cancer: examination of racial disparities surrounding access to care. J Surg Res 2017; 211:100-106. [DOI: 10.1016/j.jss.2016.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/08/2016] [Accepted: 12/09/2016] [Indexed: 10/20/2022]
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17
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Open Versus Laparoscopic Surgery for Rectal Cancer: Single-Center Results of 587 Cases. Surg Laparosc Endosc Percutan Tech 2017; 26:e62-8. [PMID: 27258918 DOI: 10.1097/sle.0000000000000267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE We aimed to compare the short-term and long-term results of laparoscopic and open rectal resections. METHODS A total of 587 rectal cancer patients were included. The main measures were demographic data, duration of surgery, early postoperative results, pathologic data, and long-term follow-up. RESULTS There were no significant differences in demographic data, morbidity rate, tumor location, and sphincter-preservation rates between the 2 groups. The duration of surgery (155 vs. 173 min, P<0.001), time to gas passage, defecation, and solid food intake and length of hospital stay were significantly shorter in the laparoscopic group than the open group (P<0.05). According to the univariate and multivariate analysis, laparoscopic surgery did not have an effect on local recurrence but had a favorable effect on survival rates. CONCLUSIONS Laparoscopic rectal surgery has advantages over open surgery with respect to short-term and long-term clinical results and when performed in high-volume centers.
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18
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Chen B, Zhang Y, Zhao S, Yang T, Wu Q, Jin C, He Y, Wang Z. The impact of general/visceral obesity on completion of mesorectum and perioperative outcomes of laparoscopic TME for rectal cancer: A STARD-compliant article. Medicine (Baltimore) 2016; 95:e4462. [PMID: 27603340 PMCID: PMC5023862 DOI: 10.1097/md.0000000000004462] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To evaluate the impact of visceral obesity on laparoscopic total mesorectal excision (TME) and decide the best index to reflect completion of mesorectum and perioperative outcomes.Patients with rectal cancer who underwent laparoscopic TME were enrolled. The data including body mass index (BMI), visceral fat area (VFA), visceral fat area/body surface area (VFA/BSA), mesorectum fat ratio (MFR), pelvic fat area (PFA), pelvic fat ratio (PFR), completion of mesorectum, and other perioperative outcomes were collected. Data were analyzed.A total of 322 patients were enrolled between 2011 and 2014. There was no significantly difference between the BMI groups on completion of mesorectum and other outcomes (P ≥ 0.05). However, in VFA groups, completion of mesorectum (P = 0.002), operative time (P = 0.02), and incision length (P = 0.02) were significantly different. In VFA/BSA groups, completion of mesorectum (P = 0.002) and incision length (P = 0.009) were significantly different. When MFR was equal to 0.48, completion of mesorectum (P = 0.002), operative time (P = 0.001), incision length (P = 0.03), and blood loss (P = 0.04) were significantly different between the 2 groups. In PFA and PFR groups, there was no significantly difference (P ≥ 0.05). After the analysis of logistic regression, only VFA was the risk factor of incomplete mesorectum excision.BMI does not reflect the impact of obesity on laparoscopic rectal surgery. VFA is a better index in predicting the influence of visceral obesity on surgical quality and difficulty of laparoscopic rectal surgery than VFA/BSA and MFR.
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Affiliation(s)
- Bingchen Chen
- The Surgical Department of Coloproctology, Zhejiang Provincial People's Hospital
| | - Yuanchuan Zhang
- Department of General Surgery, The Third People's Hospital of Chengdu
| | - Shuang Zhao
- Department of Gastrointestinal Surgery, West China Hospital
| | - Tinghan Yang
- Department of Gastrointestinal Surgery, West China Hospital
| | - Qingbin Wu
- Department of Gastrointestinal Surgery, West China Hospital
| | - Chengwu Jin
- Department of Gastrointestinal Surgery, West China Hospital
| | - Yazhou He
- Department of Gastrointestinal Surgery, West China Hospital
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital
- Correspondence: Ziqiang Wang, Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang No. 37, Chengdu 610041, Sichuan Province, China (e-mail: )
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19
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Demetter P, Jouret-Mourin A, Silversmit G, Vandendael T, Sempoux C, Hoorens A, Nagy N, Cuvelier C, Van Damme N, Penninckx F. Review of the quality of total mesorectal excision does not improve the prediction of outcome. Colorectal Dis 2016; 18:883-8. [PMID: 27586703 DOI: 10.1111/codi.13254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/21/2015] [Indexed: 12/31/2022]
Abstract
AIM A fair to moderate concordance in grading of the total mesorectal excision (TME) surgical specimen by local pathologists and a central review panel has been observed in the PROCARE (Project on Cancer of the Rectum) project. The aim of the present study was to evaluate the difference, if any, in the accuracy of predicting the oncological outcome through TME grading by local pathologists or by the review panel. METHOD The quality of the TME specimen was reviewed for 482 surgical specimens registered on a prospective database between 2006 and 2011. Patients with a Stage IV tumour, with unknown incidence date or without follow-up information were excluded, resulting in a study population of 383 patients. Quality assessment of the specimen was based on three grades including mesorectal resection (MRR), intramesorectal resection (IMR) and muscularis propria resection (MPR). Using univariable Cox regression models, local and review panel histopathological gradings of the quality of TME were assessed as predictors of local recurrence, distant metastasis and disease-free and overall survival. Differences in the predictions between local and review grading were determined. RESULTS Resection planes were concordant in 215 (56.1%) specimens. Downgrading from MRR to MPR was noted in 23 (6.0%). There were no significant differences in the prediction error between the two models; local and central review TME grading predicted the outcome equally well. CONCLUSION Any difference in grading of the TME specimen between local histopathologists and the review panel had no significant impact on the prediction of oncological outcome for this patient cohort. Grading of the quality of TME as reported by local histopathologists can therefore be used for outcome analysis. Quality control of TME grading is not warranted provided the histopathologist is adequately trained.
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Affiliation(s)
- P Demetter
- Department of Pathology, Erasme University Hospital, ULB, Brussels, Belgium
| | - A Jouret-Mourin
- Department of Pathology, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - G Silversmit
- Foundation Belgian Cancer Registry, Brussels, Belgium
| | - T Vandendael
- Foundation Belgian Cancer Registry, Brussels, Belgium
| | - C Sempoux
- Department of Pathology, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - A Hoorens
- Department of Pathology, Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - N Nagy
- Department of Pathology, CHU de Charleroi, Charleroi, Belgium
| | - C Cuvelier
- Department of Pathology, UG, Ghent, Belgium
| | - N Van Damme
- Foundation Belgian Cancer Registry, Brussels, Belgium
| | - F Penninckx
- Department of Abdominal Surgery, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
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Ihnát P, Guňková P, Peteja M, Vávra P, Pelikán A, Zonča P. Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 2016; 30:4809-4816. [PMID: 26902615 DOI: 10.1007/s00464-016-4811-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/03/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anastomotic leakage presents the most feared complication after low anterior resection (LAR). A proximal diversion of the gastrointestinal tract is recommended to avoid septic complications of anastomotic leakage. The aim of the present study was to evaluate the benefits and risks of diverting ileostomy (DI) created during laparoscopic LAR because of low rectal cancer. METHODS This was a retrospective clinical cohort study conducted to assess outcomes of laparoscopic LAR with/without DI in a single institution within a 6-year period. RESULTS In total, 151 patients were enrolled in the study (73 patients without DI, 78 patients with DI). There were no significant differences between both groups regarding demographic and clinical features. Overall 30-day morbidity rates were significantly lower in patients without DI (23.3 vs. 42.3 %, P = 0.013). Symptomatic anastomotic leakage occurred more frequently in patients without DI (9.6 vs. 2.5 %, P = 0.090); surgical intervention was needed in 6.8 % of patients without DI. Post-operative hospital stay was significantly longer in the group of patients with DI (11.3 ± 8.5 vs. 8.1 ± 6.9 days, P = 0.013). Stoma-related complications occurred in 42 of 78 (53.8 %) patients with DI; some patients had more than one complication. Acute surgery was needed in 9 patients (11.5 %) because of DI-related complications. Small bowel obstruction due to DI semi-rotation around its longitudinal axis was seen in 3 patients (3.8 %) and presents a distinct complication of DI laparoscopic construction. The mean interval between LAR and DI reversal was more than 8 months; only 19.2 % of patients were reversed without delay (≤4 months). Morbidity after DI reversal was 16.6 %; re-laparotomy was necessary in 2.5 % of patients. CONCLUSIONS The present study indicates that DI protects low rectal anastomosis from septic complications at a cost of many stoma-related complications, substantial risk of acute surgery necessity and long stoma periods coupled with decreased quality of life.
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Affiliation(s)
- Peter Ihnát
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic.
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic.
| | - Petra Guňková
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Matúš Peteja
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Petr Vávra
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Anton Pelikán
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Pavel Zonča
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
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Ferko A, Orhalmi J, Dusek T, Chobola M, Hovorkova E, Nikolov DH. Higher risk of incomplete mesorectal excision and positive circumferential margin in low rectal cancer regardless of surgical technique. Wideochir Inne Tech Maloinwazyjne 2014; 9:569-77. [PMID: 25561995 PMCID: PMC4280422 DOI: 10.5114/wiitm.2014.45733] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/24/2014] [Accepted: 09/14/2014] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Currently, the predominant question is whether a laparoscopic approach is comparatively radical in comparison with an open access approach, especially in the circumferential resection margin and quality of the completeness of total mesorectal excision. These factors are important in determining the quality of surgical care as well as long-term results of the treatment. AIM This article focuses on the evaluation of circumferential resection margins and on the quality of mesorectal excision of middle and lower rectum tumors. In addition, laparoscopic and open techniques are compared. MATERIAL AND METHODS Data were collected prospectively and stored in a rectal cancer registry over a 3-year period. The parameters studied were age, sex, body mass index, localization and topography of the tumor, clinical stage, neoadjuvant chemotherapy and its response, the type of surgery, character of the circumferential and distal margins, quality of the mesorectal excision, pT and pN. RESULTS One hundred and twenty-five patients were chosen for our study. Laparoscopy was performed in 53 operations and a conventional approach was performed in 72 operations. Complete mesorectal excision was achieved in 54.7% of laparoscopic operations versus 44.4% in the conventional technique; partially complete excision was performed in 20.8 and 12.5%, respectively. Incomplete excisions were described in 24.5 and 43.1% (p = 0.085). Positive circumferential margin occurred during laparoscopic surgery in 11 (20.8%) patients, and in the case of conventional resection in 27 (37.5%) patients (p = 0.044). CONCLUSIONS Our study showed comparable results between laparoscopic and open access procedures during rectal resection. The results achieved, in particular in the quality of the mesorectal excision and negative circumferential resection margin, show that the laparoscopic approach is comparable to conventional surgical techniques, with an adequate surgical outcome, in the treatment of rectal cancer.
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Affiliation(s)
- Alexander Ferko
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Julius Orhalmi
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Tomas Dusek
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
- Department of Military Surgery, Faculty of Military Health Sciences, University of Defense, Hradec Kralove, Czech Republic
| | - Milan Chobola
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Eva Hovorkova
- The Fingerland Department of Pathology, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Dimitar Hadzi Nikolov
- The Fingerland Department of Pathology, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
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Madbouly KM, Hussein AM, Abdelzaher E. Long-term prognostic value of mesorectal grading after neoadjuvant chemoradiotherapy for rectal cancer. Am J Surg 2014; 208:332-41. [PMID: 24581995 DOI: 10.1016/j.amjsurg.2013.10.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 09/22/2013] [Accepted: 10/03/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mesorectal grading was reported to be a valuable prognostic factor in rectal cancer surgery. Previous studies were retrospective, and had short follow-up. OBJECTIVE To assess the long-term influence of total mesorectal excision quality on disease recurrence in mid and low rectal cancer patients who received preoperative neoadjuvant chemoradiotherapy (CRT) and postoperative chemotherapy. METHODS One hundred twenty-one patients with rectal cancer had either low anterior resection or abdominoperineal resection. All patients received neoadjuvant CRT and postoperative chemotherapy. Main outcome measures included TNM staging, involvement of the circumferential resection margin (ICRM), mesorectal grading, local and systemic recurrences were recorded. RESULTS Follow-up was done for at least 5 years or up to disease recurrence whatever comes first. Mean follow-up time was 59.4 months. Twenty-nine patients had abdominoperineal resection and 92 had low anterior resection. About 7.5% had positive CRM which was significantly correlated with mesorectal grading. Grade 3 mesorectal specimens were obtained in approximately 60% of patients, 27% had grade 2, and only 13% had grade 1 (poor) mesorectal specimens. Poorer mesorectal grading increased with APR and lower rectal tumors. Recurrences occurred in 20% of patients (40% in the first 2 years, 32% in the 3rd year, and 28% in the 4th and 5th years); factors affecting recurrence included lymphovascular invasion, ICRM, and N stage. Mesorectal grading was not a valuable prognostic factor for recurrence unless it resulted in ICRM. Recurrences occurred earlier with poorer mesorectal grade, yet this was not statistically significant. CONCLUSIONS Mesorectal grading is a pathologic description that reflects the quality of surgery. However, in patients who received neoadjuvant CRT and postoperative chemotherapy, grading had no long-term prognostic value regarding recurrences unless it resulted in ICRM.
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Affiliation(s)
- Khaled M Madbouly
- Department of Surgery, University of Alexandria, El Raml Station, Alexandria, Egypt.
| | - Ahmed M Hussein
- Department of Surgery, University of Alexandria, El Raml Station, Alexandria, Egypt
| | - Eman Abdelzaher
- Department of Pathology, University of Alexandria, El Raml Station, Alexandria, Egypt
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Bai X, Li S, Yu B, Su H, Jin W, Chen G, DU J, Zuo F. Sphincter-preserving surgery after preoperative radiochemotherapy for T3 low rectal cancers. Oncol Lett 2012; 3:1336-1340. [PMID: 22783445 DOI: 10.3892/ol.2012.656] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 03/19/2012] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to evaluate the feasibility and the effectiveness of preoperative radiochemotherapy followed by total mesorectal excision (TME) and sphincter-preserving procedures for T3 low rectal cancer. Patients with rectal cancer and T3 tumors located within 1-6 cm of the dentate line received preoperative radiochemotherapy. Concurrent 5-fluorouracil-based radiochemotherapy was used. Radical resection with TME and sphincter-preserving procedures were performed during the six to eight weeks following radiotherapy. Survival was analyzed using the Kaplan-Meier method. The anal function was evaluated using the Wexner score. The clinical response rate was 83.5%, overall downstaging of T classification was 75.3% and pathological complete response was 15.3%. The anastomotic fistula rate was 4.7%. A median follow-up of 30 months showed the local recurrence rate to be 4.7% and the distant metastasis rate to be 5.9%. The three-year overall survival rate was 87%. The degree of anal incontinence as measured using the Wexner score decreased over time, and the anal sphincter function in the majority of patients gradually improved. Preoperative radiochemotherapy was found to improve tumor downstaging, reduces local recurrence, increase the sphincter preservation rate, and is therefore of benefit to patients with T3 low rectal cancer.
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Affiliation(s)
- Xue Bai
- Department of General Surgery, The Military General Hospital of Beijing PLA, Beijing 100700, P.R. China
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Postoperative adjuvant chemotherapy for stage II colorectal cancer: a systematic review of 12 randomized controlled trials. J Gastrointest Surg 2012; 16:646-55. [PMID: 22194062 DOI: 10.1007/s11605-011-1682-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 09/07/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of postoperative adjuvant chemotherapy on the oncological outcomes for stage II colorectal cancer remains controversial. METHODS The literature was searched for studies published between 1985 and 2010 in which patients with stage II colorectal cancer were randomly assigned to receive either surgery combined with postoperative adjuvant chemotherapy or surgery alone. End points included 5-year overall survival, 5-year disease-free survival, recurrence, and mortality. RESULTS A significant improvement in 5-year overall survival was associated with surgery combined with postoperative adjuvant chemotherapy for stage II colon cancer (hazard ratio, 0.81; 95% confidence interval (CI), 0.71-0.91) and for stage II rectal cancer (hazard ratio, 0.72; 95% CI, 0.61-0.86). The 5-year disease-free survival also favored the group of surgery combined with postoperative adjuvant chemotherapy for stage II colon cancer (hazard ratio, 0.86; 95% CI, 0.75-0.98) and for stage II rectal cancer (hazard ratio, 0.34; 95% CI, 0.22-0.51). For stage II colon cancer, a significant reduction in risk of recurrence was found in favor of postoperative adjuvant chemotherapy (risk ratio, 0.82; 95% CI, 0.71-0.95). CONCLUSIONS Postoperative adjuvant chemotherapy for stage II colorectal cancer appears to be associated with improved 5-year overall survival and 5-year disease-free survival, and reduction in risk of recurrence.
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