1
|
Bratu LD, Schenker M, Stovicek PO, Schenker RA, Mehedințeanu AM, Berisha TC, Donoiu A, Mogoantă SȘ. Retrospective Evaluation of the Efficacy of Total Neoadjuvant Therapy and Chemoradiotherapy Neoadjuvant Treatment in Relation to Surgery in Patients with Rectal Cancer. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:656. [PMID: 38674302 PMCID: PMC11052151 DOI: 10.3390/medicina60040656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/14/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
Background and Objective: In the therapeutic strategy of rectal cancer, radiotherapy has consolidated its important position and frequent use in current practice due to its indications as neoadjuvant, adjuvant, definitive, or palliative treatment. In recent years, total neoadjuvant therapy (TNT) has been established as the preferred regimen compared to concurrent neoadjuvant chemoradiotherapy (CRT). In relation to better outcomes, the percentage of patients who achieved pathological complete response (pCR) after neoadjuvant treatment is higher in the case of TNT. This study aimed to analyze the response to TNT compared to neoadjuvant CRT regarding pCR rate and the change in staging after surgical intervention. Materials and Methods: We performed a retrospective study on 323 patients with rectal cancer and finally analyzed the data of 201 patients with neoadjuvant treatment, selected based on the inclusion and exclusion criteria. Patients received CRT neoadjuvant therapy or TNT neoadjuvant therapy with FOLFOX or CAPEOX. Results: Out of 157 patients who underwent TNT treatment, 19.74% had pathological complete response, whereas in the group with CRT (n = 44), those with pCR were 13.64%. After neoadjuvant treatment, the most frequent TNM classifications were ypT2 (40.30%) and ypN0 (79.10%). The statistical analysis of the postoperative disease stage, after neoadjuvant therapy, showed that the most frequent changes were downstaging (71.14%) and complete response (18.41%). Only four patients (1.99%) had an upstaging change. The majority of patients (88.56%) initially presented clinical evidence of nodal involvement whereas only 20.9% of the patients still presented regional disease at the time of surgical intervention. Conclusions: By using TNT, a higher rate of stage reduction is obtained compared to the neoadjuvant CRT treatment. The post-neoadjuvant-treatment imagistic evaluation fails to accurately evaluate the response. A better response to TNT was observed in young patients.
Collapse
Affiliation(s)
- Lucian Dragoș Bratu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania (T.C.B.); (A.D.)
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
| | - Michael Schenker
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
- Department of Oncology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Puiu Olivian Stovicek
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
- Department of Pharmacology, Faculty of Nursing, Târgu Jiu Subsidiary, Titu Maiorescu University, 040441 Bucharest, Romania
| | | | | | - Tradian Ciprian Berisha
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania (T.C.B.); (A.D.)
- Sf. Nectarie Oncology Center, 200347 Craiova, Romania; (R.A.S.); (A.M.M.)
| | - Andreas Donoiu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania (T.C.B.); (A.D.)
- 3rd General Surgery Clinic, Emergency County Hospital, 200642 Craiova, Romania;
| | - Stelian Ștefăniță Mogoantă
- 3rd General Surgery Clinic, Emergency County Hospital, 200642 Craiova, Romania;
- Department of Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| |
Collapse
|
2
|
Varlamos CJ, Sinco B, Van Weiren I, Regenbogen S, Gamboa AC, Silviera M, Abdel-Misih SRZ, Hawkins AT, Balch G, Hendren S. Close distal margin is associated with locoregional rectal cancer recurrence: A multicenter study. J Surg Oncol 2023; 128:1106-1113. [PMID: 37458131 DOI: 10.1002/jso.27401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND OBJECTIVES The importance of the radial margin for rectal cancer resection is well understood. However, surgeons have deemphasized the distal margin, accepting very close distal margins to perform sphincter-preserving surgery. We hypothesized that distal margins < 1 cm would be an independent risk factor for locoregional recurrence. The objective was to determine whether close distal margins are associated with increased locoregional recurrence risk. METHODS This was a multi-institutional retrospective cohort study conducted at six academic medical centers including patients who received low anterior resection surgery for primary rectal cancer between 2007 and 2018. RESULTS Of 556 low anterior resection patients, the rate of close distal margin was 12.8% (n = 71), and the locoregional recurrence rate was 5.0% (n = 28). The locoregional recurrence rate for close distal margin cases was 9.9% (n = 7) compared to 4.3% (n = 21) for distal margins ≥1.0 cm. In multivariable analysis, the only factor significantly associated with locoregional recurrence was close distal margin (adjusted odds ratio: 2.80, confidence interval: 1.08-7.25, p = 0.035). CONCLUSIONS Rectal cancer patients with close distal margins (<1 cm) following low anterior resection had a significantly higher risk for locoregional recurrence. Therefore, the decision to perform low anterior resection with margins < 1 cm should be taken with caution.
Collapse
Affiliation(s)
| | - Brandy Sinco
- Department of Surgery, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Inga Van Weiren
- Department of Surgery, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Scott Regenbogen
- Department of Surgery, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Adriana C Gamboa
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew Silviera
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sherif R Z Abdel-Misih
- Department of Surgery (Surgical Oncology), Stony Brook University Hospital, Stony Brook, New York, USA
| | - Alexander T Hawkins
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Glen Balch
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
3
|
Kim HJ, Choi GS, Song SH, Park JS, Park SY, Lee SM, Na DH, Jeong MH. Single-Port Robotic Intersphincteric Resection for the Treatment of Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2023; 33:249-255. [PMID: 37172021 DOI: 10.1097/sle.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/20/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND The da Vinci Single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of intersphincteric resection (ISR) using the SP platform and evaluated the technical safety and feasibility of this procedure for the treatment of very low rectal cancer. MATERIALS AND METHODS Eleven rectal cancer patients who underwent SP robotic ISR between August 2020 and July 2021 were included. Patients' clinical characteristics, operative and pathologic findings of the patients were retrospectively analyzed. RESULTS The median tumor height was 3 cm (range, 2-4 cm). A single docking was performed, and the median docking time was 3 min 10 sec (range, 2 min 50 sec-3 min 30 sec). The median total operation time was 210 min (range, 150-280 min), and the median time of pelvic dissection was 57 min (range, 45-68 min). All patients presented with negative distal resection margins [median 1 cm (range, 0.5-2.0 cm)], and only one patient had less than 1mm of circumferential resection margin (0.9 mm). CONCLUSIONS Our initial experience suggests that SP robotic ISR is safe and feasible.
Collapse
Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Sorrentino L, Sileo A, Daveri E, Battaglia L, Guaglio M, Centonze G, Sabella G, Patti F, Villa S, Milione M, Belli F, Cosimelli M. Impact of Microscopically Positive (≤1 mm) Distal Margins on Disease Recurrence in Rectal Cancer Treated by Neoadjuvant Chemoradiotherapy. Cancers (Basel) 2023; 15:cancers15061828. [PMID: 36980714 PMCID: PMC10047023 DOI: 10.3390/cancers15061828] [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: 02/10/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND The adequate distal resection margin is still controversial in rectal cancer treated by neoadjuvant chemoradiotherapy (nCRT). The aim of this study was to assess the impact of a distal margin of ≤1 mm on locoregional recurrence-free survival (LRRFS). METHODS Among 255 patients treated with nCRT and surgery at the National Cancer Institute of Milan, 83 (32.5%) had a distal margin of ≤1 mm and 172 (67.5%) had a distal margin of >1 mm. Survival analyses were performed to assess the impact of distal margin on 5-year LRRFS, as well as Cox survival analysis. The role of distal margin on survival was analyzed according to different tumor regression grades (TRGs). RESULTS The overall 5-year LRRFS rate was 77.6% with a distal margin of ≤1 mm vs. 88.3% with a distal margin of >1 mm (Log-rank p = 0.09). Only stage ypT4 was an independent predictor of worse LRRFS (HR 15.14, p = 0.026). The 5-year LRRFS was significantly lower in TRG3-5 patients with a distal margin of ≤1 mm compared to those with a distal margin of >1 mm (68.5% vs. 84.2%, p = 0.027), while no difference was observed in case of TRG1-2 (p = 0.77). CONCLUSIONS Low-responder rectal cancers after nCRT still require a distal margin of >1 mm to reduce the high likelihood of local relapse.
Collapse
Affiliation(s)
- Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Annaclara Sileo
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Elena Daveri
- Immunotherapy of Human Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Luigi Battaglia
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Marcello Guaglio
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Giovanni Centonze
- 1st Pathology Division, Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Giovanna Sabella
- 1st Pathology Division, Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Filippo Patti
- Radiation Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Sergio Villa
- Radiation Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Massimo Milione
- 1st Pathology Division, Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Filiberto Belli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| |
Collapse
|
5
|
Bediako-Bowan AAA, Naalane N, Dakubo JCB. Morbidity and oncological outcomes after intersphincteric resection of the rectum for low-lying rectal cancer: experience of a single center in a lower-middle-income country. BMC Surg 2023; 23:39. [PMID: 36805711 PMCID: PMC9938915 DOI: 10.1186/s12893-023-01940-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Intersphincteric resection (ISR) of the rectum for low-lying rectal cancer with colo-anal anastomosis was introduced years ago, allowing for bowel continuity, and avoiding permanent stomas. The colorectal unit of Korle Bu Teaching Hospital adopted this procedure in 2014 when indicated, for the management of rectal cancers, where hitherto, abdominoperineal resection of the rectum with a permanent stoma was indicated. This study aimed to assess morbidity, mortality, and oncological outcomes associated with ISR of the rectum and determine the factors contributing to these. METHODS This was an observational study from prospectively stored data. All patients who underwent intersphincteric resection of the rectum due to low-lying rectal cancer from July 2014 to June 2021 were included in the study, and their records were assessed for intra-operative and 30-day postoperative complications, as well as mortality and their related risk factors and their oncological outcomes in terms of local recurrence at one year. RESULTS 102 patients were included in this analysis. Six percent (6/102) of patients had intra-operative complications, including bleeding, and 41% (42/102) had 30-day postoperative complications, which were associated with pelvic side wall attachment of tumor and intra-op complications. Mortality risk was 12.7% (13/102) in the early postoperative period, and nine patients had a local recurrence within the first year of surgery. CONCLUSION There is a high risk of early postoperative morbidity and mortality after intersphincteric resection of the rectum in our setting. The oncological outcomes are favorable in a population that abhors a permanent colostomy.
Collapse
Affiliation(s)
- Antoinette Afua Asiedua Bediako-Bowan
- Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4236, Accra, Ghana. .,Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana. .,Mwin Tuba Hospital and Coloproctology Centre, Accra, Ghana.
| | - Narious Naalane
- grid.415489.50000 0004 0546 3805Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana
| | - Jonathan C. B. Dakubo
- grid.8652.90000 0004 1937 1485Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4236, Accra, Ghana ,grid.415489.50000 0004 0546 3805Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana ,Mwin Tuba Hospital and Coloproctology Centre, Accra, Ghana
| |
Collapse
|
6
|
Required distal mesorectal resection margin in partial mesorectal excision: a systematic review on distal mesorectal spread. Tech Coloproctol 2023; 27:11-21. [PMID: 36036328 PMCID: PMC9807492 DOI: 10.1007/s10151-022-02690-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 08/15/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The required distal margin in partial mesorectal excision (PME) is controversial. The aim of this systematic review was to determine incidence and distance of distal mesorectal spread (DMS). METHODS A systematic search was performed using PubMed, Embase and Google Scholar databases. Articles eligible for inclusion were studies reporting on the presence of distal mesorectal spread in patients with rectal cancer who underwent radical resection. RESULTS Out of 2493 articles, 22 studies with a total of 1921 patients were included, of whom 340 underwent long-course neoadjuvant chemoradiotherapy (CRT). DMS was reported in 207 of 1921 (10.8%) specimens (1.2% in CRT group and 12.8% in non-CRT group), with specified distance of DMS relative to the tumor in 84 (40.6%) of the cases. Mean and median DMS were 20.2 and 20.0 mm, respectively. Distal margins of 40 mm and 30 mm would result in 10% and 32% residual tumor, respectively, which translates into 1% and 4% overall residual cancer risk given 11% incidence of DMS. The maximum reported DMS was 50 mm in 1 of 84 cases. In subgroup analysis, for T3, the mean DMS was 18.8 mm (range 8-40 mm) and 27.2 mm (range 10-40 mm) for T4 rectal cancer. CONCLUSIONS DMS occurred in 11% of cases, with a maximum of 50 mm in less than 1% of the DMS cases. For PME, substantial overtreatment is present if a distal margin of 5 cm is routinely utilized. Prospective studies evaluating more limited margins based on high-quality preoperative magnetic resonance imaging and pathological assessment are required.
Collapse
|
7
|
Metwally IH, Zuhdy M, Hamdy O, Fareed AM, Elbalka SS. The Impact of Narrow and Infiltrated Distal Margin After Proctectomy for Rectal Cancer on Patients' Outcomes: a Systematic Review and Meta-analysis. Indian J Surg Oncol 2022; 13:750-760. [PMID: 36687255 PMCID: PMC9845496 DOI: 10.1007/s13193-022-01565-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 06/09/2022] [Indexed: 01/25/2023] Open
Abstract
Rectal cancer is a common tumor within a difficult anatomic constraint. Total mesorectal excision with longitudinal and circumferential free margins is considered imperative for good prognosis. In this article, the authors systematically reviewed all published literature with specific Mesh terms until the end of year 2019. Thereafter, retrieved articles were assessed using the Newcastle-Ottawa Scale and meta-analysis was conducted comparing local recurrence among 1-cm, 5-mm, and narrow (< 1-mm)/infiltrated margins. Thirty-nine articles were included in the study. Macroscopic distal margin < 1 cm carried a higher incidence of recurrence for those who did not receive neoadjuvant radiation, without affecting neither estimated overall nor disease-free survival. Less than 5-mm margin after radiation therapy is accepted oncologically. Infiltrated margins and narrow margins (< 1 mm) microscopically are associated with higher incidence of local recurrence and shorter overall and disease-free survival. Surgeons should aim at 1-cm safety margin in radiotherapy-naïve patients and microscopic free margin > 1 mm for those who received neoadjuvant therapy. The cost/benefit of reoperation for patients with infiltrated margins is still inadequately studied.
Collapse
Affiliation(s)
- Islam H. Metwally
- Surgical Oncology department, Oncology Center Mansoura University (OCMU), Geehan Street, Dakahlia Governorate 35516 Mansoura City, Egypt
| | - Mohammad Zuhdy
- Surgical Oncology department, Oncology Center Mansoura University (OCMU), Geehan Street, Dakahlia Governorate 35516 Mansoura City, Egypt
| | - Omar Hamdy
- Surgical Oncology department, Oncology Center Mansoura University (OCMU), Geehan Street, Dakahlia Governorate 35516 Mansoura City, Egypt
| | - Ahmed M. Fareed
- Surgical Oncology department, Oncology Center Mansoura University (OCMU), Geehan Street, Dakahlia Governorate 35516 Mansoura City, Egypt
| | - Saleh S. Elbalka
- Surgical Oncology department, Oncology Center Mansoura University (OCMU), Geehan Street, Dakahlia Governorate 35516 Mansoura City, Egypt
| |
Collapse
|
8
|
Yan H, Wang PY, Wu YC, Liu YC. Is a Distal Resection Margin of ≤ 1 cm Safe in Patients with Intermediate- to Low-Lying Rectal Cancer? A Systematic Review and Meta-Analysis. J Gastrointest Surg 2022; 26:1791-1803. [PMID: 35501549 DOI: 10.1007/s11605-022-05342-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is generally accepted that the distal resection margin of intermediate- to low-lying rectal cancer should be greater than 2 cm and at least 1 cm in special cases. This study intends to investigate whether a distal resection margin ≤ 1 cm affects tumor outcomes for patients with intermediate- to low-lying rectal cancer. METHODS A systematic review of the literature was conducted. Sixteen studies included data for distal resection margins ≤ 1 cm (1684 cases) and > 1 cm (5877 cases), and 5 studies included survival data. Meta-analysis was used to compare the local recurrence rate and long-term survival of patients with distal resection margins > or ≤ 1 cm. RESULTS The local recurrence rate in the ≤ 1-cm margin group (9.5%) was 2.3% higher than that in the > 1-cm margin group (7.2%) according to a fixed-effects model (RR [95% CI] 1.42 [1.18, 1.70], P < 0.001). The overall survival results of the five 1-cm margin studies showed an HR (95% CI) of 0.96 (0.75, 1.24) (P = 0.78). Subgroup analysis showed that the local recurrence rate in the subgroup with perioperative treatment was 1.2% lower in the ≤ 1-cm margin group (8.3%) than in the > 1-cm margin group (9.5%) (RR [95% CI] 0.97 [0.63, 1.49], P = 0.90). In the surgery alone subgroup, the local recurrence rate was 4.7% higher in the ≤ 1-cm margin group (12.4%) than in the > 1-cm group (7.7%) (RR [95% CI] 1.76 [1.09, 2.83], P = 0.02). CONCLUSIONS For patients with intermediate- to low-lying rectal cancer undergoing surgery alone, a distal resection margin ≤ 1 cm may be not safe.
Collapse
Affiliation(s)
- Han Yan
- Department of General Surgery, Peking University First Hospital, Xishiku Street No 8, Xicheng District, Beijing, China
| | - Peng-Yuan Wang
- Department of General Surgery, Peking University First Hospital, Xishiku Street No 8, Xicheng District, Beijing, China
| | - Ying-Chao Wu
- Department of General Surgery, Peking University First Hospital, Xishiku Street No 8, Xicheng District, Beijing, China.
| | - Yu-Cun Liu
- Department of General Surgery, Peking University First Hospital, Xishiku Street No 8, Xicheng District, Beijing, China.
| |
Collapse
|
9
|
Maguire B, Clancy C, Connelly TM, Mehigan BJ, McCormick P, Altomare DF, Gosselink MP, Larkin JO. Quality of life meta-analysis following coloanal anastomosis versus abdominoperineal resection for low rectal cancer. Colorectal Dis 2022; 24:811-820. [PMID: 35194919 DOI: 10.1111/codi.16099] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 12/13/2022]
Abstract
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.
Collapse
Affiliation(s)
- Barry Maguire
- Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland
| | - Cillian Clancy
- Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland
| | - Tara M Connelly
- Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland
| | - Brian J Mehigan
- Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland
- School of Medicine, Trinity College, University of Dublin, Dublin, Ireland
| | - Paul McCormick
- Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland
- School of Medicine, Trinity College, University of Dublin, Dublin, Ireland
| | - Donato F Altomare
- Surgical Unit Department of Emergency and Organ Transplantation, University of Aldo Moro of Bari, Bari, Italy
| | | | - John O Larkin
- Department of Colorectal Surgery, Saint James's Hospital, Dublin, Ireland
- School of Medicine, Trinity College, University of Dublin, Dublin, Ireland
| |
Collapse
|
10
|
Zhang C, Cui M, Xing J, Yang H, Su X. Oncological results in rectal cancer patients with a subcentimetre distal margin after laparoscopic-assisted sphincter-preserving surgery. ANZ J Surg 2022; 92:1454-1460. [PMID: 35088533 PMCID: PMC9305552 DOI: 10.1111/ans.17503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 01/04/2023]
Abstract
Background Distal resection margin (DRM) is closely associated with sphincter‐preserving surgery and oncological safety for patients with mid‐low rectal cancers. However, the optimal DRM has not been determined. Methods Data of 378 rectal cancer patients who underwent laparoscopic‐assisted sphincter‐preserving surgery from 2009 to 2015 were retrospectively analysed. Patients were divided into two groups based on DRM: ≤1 cm (n = 74) and >1 cm (n = 304). To minimize the differences between the two groups, propensity‐score matching on baseline features was performed. Results Before propensity‐score matching, no significant differences in 5‐year disease‐free survival (DFS) (92.8% versus 81.3%, P = 0.128) and 5‐year overall survival (OS) (83.7% versus 82.2%, P = 0.892) were observed in patients with DRMs of ≤1 cm (n = 74) and >1 cm (n = 304), respectively. After propensity‐score matching (1:1), there were also no significant differences in DFS (88.1% versus 78.2%, P = 0.162) and OS (84.5% versus 84.9%, P = 0.420) between the DRM of ≤1 cm group (n = 65) and >1 cm group (n = 65), respectively. A total of 44 patients received preoperative chemoradiotherapy (CRT). In this cohort, the 5‐year local recurrence (LR) rates (P = 0.118) and the 5‐year DFS rates (P = 0.298) were not significantly different between the two groups. A total of 334 patients received surgery without neoadjuvant CRT. There were also no significant differences in the 5‐year LR rates (P = 0.150) and 5‐year DFS rates (P = 0.172) between the two groups. Conclusions When aiming to achieve at least a 1–2 cm distal clinical resection margin, a histological resection margin of <1 cm on the DRM gave equivalent clinical outcomes to a DRM of >1 cm.
Collapse
Affiliation(s)
- Chenghai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jiadi Xing
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, China
| |
Collapse
|
11
|
Schietroma M, Romano L, Apostol AI, Vada S, Necozione S, Carlei F, Giuliani A. Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials. Int J Colorectal Dis 2022; 37:71-99. [PMID: 34716474 DOI: 10.1007/s00384-021-04048-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce. OBJECTIVE The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer. DATA SOURCES A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words. STUDY SELECTION Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. INTERVENTION(S) This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer. MAIN OUTCOME MEASURES Primary outcomes were oncological parameters. RESULTS Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group. LIMITATIONS There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique. CONCLUSIONS Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.
Collapse
Affiliation(s)
- Mario Schietroma
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Lucia Romano
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy.
| | - Adriana Ionelia Apostol
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Silvia Vada
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Stefano Necozione
- Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Carlei
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| | - Antonio Giuliani
- Department of Biotechnological and Applied Clinical Science, General Surgery, University of L'Aquila, San Salvatore Hospital, Coppito (AQ), 67100, L'Aquila, Italy
| |
Collapse
|
12
|
Park EJ, Baik SH. Functional outcomes after sphincter-preserving surgeries for low-lying rectal cancer: A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Sphincter preservation and organ restoration during rectal cancer surgery avoids permanent stoma creation and diminishes psychosocial damages. However, decreased rectal volumes and sphincter dysfunction—including pelvic nerve damage—results in low anterior resection syndrome, as well as urinary and sexual dysfunction after rectal resection. Bowel habit changes such as fecal incontinence, fecal urgency, frequent bowel movements, clustered stools, and difficulties in bowel emptying can be treated using medications, pelvic floor rehabilitation, sacral neuromodulation, or neorectal reservoir reconstruction. Pelvic nerve damage resulting from superior and inferior hypogastric plexi during sphincter-preserving rectal cancer surgery can induce urologic and sexual dysfunctions. Preoperative voiding difficulty, perioperative blood loss, and autonomic nerve injury are considered independent risk factors for postoperative urinary dysfunction. Retrograde ejaculation and erectile dysfunction, female dyspareunia, and vaginal dryness are manifestations of sexual dysfunction resulting from autonomic nerve injury during rectal cancer surgery. Multifactorial causes for functional outcomes after sphincter- preserving surgeries are considered to improve patient’s quality of life with acceptable oncologic outcomes in the treatment of rectal cancer patients.
Collapse
|
13
|
Piozzi GN, Baek SJ, Kwak JM, Kim J, Kim SH. Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection. Cancers (Basel) 2021; 13:4793. [PMID: 34638278 PMCID: PMC8507715 DOI: 10.3390/cancers13194793] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.
Collapse
Affiliation(s)
| | | | | | | | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (G.N.P.); (S.-J.B.); (J.-M.K.); (J.K.)
| |
Collapse
|
14
|
Jiménez-Toscano M, Montcusí B, Ansuátegui M, Alonso S, Salvans S, Pascual M, Pera M. Oncological outcome of wide anatomic resection with partial mesorectal excision in patients with upper and middle rectal cancer. Colorectal Dis 2021; 23:1837-1847. [PMID: 33900002 DOI: 10.1111/codi.15690] [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: 12/03/2020] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/27/2022]
Abstract
AIM The aim was to investigate the influence of distal resection margin and extent of mesorectal excision on long-term oncological outcomes. METHOD Consecutive patients with upper and middle third rectal cancer from June 2006 to February 2016 were reviewed. Patients were divided into four groups depending on the distal margin considered as a surrogate marker of the extension of mesorectal excision (Q1 ≤10 mm, Q2 11-20 mm, Q3 21-30 mm, Q4 ≥31 mm). Local-recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS) were estimated. Cox regression models were used to investigate the influence of surgical and clinicopathological variables on prognosis by adjusting for confounding factors. RESULTS Two hundred and eleven patients with mid (125) and upper (86) rectal cancer underwent wide mesorectal excision. The median follow-up was 48.64 months (interquartile range 28-63). 17.5% patients developed recurrence. The 5-year LRFS, DFS and OS for all patients were 93.20%, 83.89% and 80.1%, respectively, with no statistically significant differences between groups (LRFS, P = 0.601; DFS, P = 0.487; OS, P = 0.468). In the multivariable analysis the recurrences and survival were associated with the quality of the mesorectum (LRFS, hazard ratio 10.629, 95% CI 2.324-48.610, P = 0.002; DFS, hazard ratio 2.789, 95% CI 1.314-5.922, P = 0.008). CONCLUSION A wide anatomical resection with partial mesorectal excision and shorter distal resection margin does not jeopardize the oncological outcomes.
Collapse
Affiliation(s)
- Marta Jiménez-Toscano
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain.,Colorectal Cancer Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Blanca Montcusí
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain.,Colorectal Cancer Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Marina Ansuátegui
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Sandra Alonso
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain.,Colorectal Cancer Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Silvia Salvans
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain.,Colorectal Cancer Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Marta Pascual
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain.,Colorectal Cancer Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Miguel Pera
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain.,Colorectal Cancer Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| |
Collapse
|
15
|
Ghezzi TL, Tarta C, Contu PC, Lazzaron AR, Contin BM, Kliemann LM, Damin DC. Distal resection margins in rectal cancer specimens: differences in assessment between surgeons and pathologists and the influence of neoadjuvant chemoradiation. Updates Surg 2021; 73:1787-1793. [PMID: 34100187 DOI: 10.1007/s13304-021-01102-7] [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: 04/22/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022]
Abstract
To investigate the discrepancy between the distal resection margin (DRM) assessed by surgeons and pathologists, and the impact of neoadjuvant chemoradiotherapy (nCRT) on DRM. This study included 67 rectal cancer patients undergoing elective surgery. DRMs were assessed through four different techniques: in vivo subjective estimative, made by the surgeon before the rectal resection (by palpation and visual estimative); in vivo objective, measured with a ruler before the rectal transection; ex vivo objective, measured right after resection of the specimen; post-fixation objective measurement, conducted by the pathologist. The DRMs subjectively and objectively assessed by the surgeons were not significantly different (3.40 cm vs. 3.45 cm). There was a mean reduction in the length of DRMs of 35.6%, from 3.45 cm objectively measured by the surgeon to 2.20 cm measured by the pathologist. This difference was significant among patients that did not receive nCRT (3.90 cm vs. 2.30 cm, P < 0.001), but not among those who received nCRT (2.30 vs. 2.05 cm). Surgeons are accurate in assessing rectal cancer DRMs. There are significant differences between intraoperative measurements of DRMs and the final pathologic results. However, these differences are not seen when nCRT is used, a finding that may be useful when sphincter preservation is being considered.
Collapse
Affiliation(s)
- T L Ghezzi
- Division of Coloproctology, Hospital de Clínica de Porto Alegre, Rua Ramiro Barcelos 2350, sala (room) 600, Porto Alegre, Rio Grande Do Sul, 90 035-903, Brazil
| | - C Tarta
- Division of Coloproctology, Hospital de Clínica de Porto Alegre, Rua Ramiro Barcelos 2350, sala (room) 600, Porto Alegre, Rio Grande Do Sul, 90 035-903, Brazil
| | - P C Contu
- Division of Coloproctology, Hospital de Clínica de Porto Alegre, Rua Ramiro Barcelos 2350, sala (room) 600, Porto Alegre, Rio Grande Do Sul, 90 035-903, Brazil
| | - A R Lazzaron
- Division of Coloproctology, Hospital de Clínica de Porto Alegre, Rua Ramiro Barcelos 2350, sala (room) 600, Porto Alegre, Rio Grande Do Sul, 90 035-903, Brazil
- Postgratuate Program in Surgical Sciences, School of Medicine, Federal University of Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - B M Contin
- Postgratuate Program in Surgical Sciences, School of Medicine, Federal University of Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - L M Kliemann
- Department of Pathology, School of Medicine, Federal University of Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - D C Damin
- Division of Coloproctology, Hospital de Clínica de Porto Alegre, Rua Ramiro Barcelos 2350, sala (room) 600, Porto Alegre, Rio Grande Do Sul, 90 035-903, Brazil.
- Postgratuate Program in Surgical Sciences, School of Medicine, Federal University of Rio Grande Do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
| |
Collapse
|
16
|
Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl) 2021; 133:1824-1833. [PMID: 32604174 PMCID: PMC7469998 DOI: 10.1097/cm9.0000000000000852] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients’ quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.
Collapse
|
17
|
Chen ZZ, Li YD, Huang W, Chai NH, Wei ZQ. Colonic pouch confers better bowel function and similar postoperative outcomes compared to straight anastomosis for low rectal cancer. World J Gastrointest Surg 2021; 13:303-314. [PMID: 33796217 PMCID: PMC7992999 DOI: 10.4240/wjgs.v13.i3.303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/02/2021] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With advancements in laparoscopic technology and the wide application of linear staplers, sphincter-saving procedures are increasingly performed for low rectal cancer. However, sphincter-saving procedures have led to the emergence of a unique clinical disorder termed anterior rectal resection syndrome. Colonic pouch anastomosis improves the quality of life of patients with rectal cancer > 7 cm from the anal margin. But whether colonic pouch anastomosis can reduce the incidence of rectal resection syndrome in patients with low rectal cancer is unknown.
AIM To compare postoperative and oncological outcomes and bowel function of straight and colonic pouch anal anastomoses after resection of low rectal cancer.
METHODS We conducted a retrospective study of 72 patients with low rectal cancer who underwent sphincter-saving procedures with either straight or colonic pouch anastomoses. Functional evaluations were completed preoperatively and at 1, 6, and 12 mo postoperatively. We also compared perioperative and oncological outcomes between two groups that had undergone low or ultralow anterior rectal resection.
RESULTS There were no significant differences in mean operating time, blood loss, time to first passage of flatus and excrement, and duration of hospital stay between the colonic pouch and straight anastomosis groups. The incidence of anastomotic leakage following colonic pouch construction was lower (11.4% vs 16.2%) but not significantly different than that of straight anastomosis. Patients with colonic pouch construction had lower postoperative low anterior resection syndrome scores than the straight anastomosis group, suggesting better bowel function (preoperative: 4.71 vs 3.89, P = 0.43; 1 mo after surgery: 34.2 vs 34.7, P = 0.59; 6 mo after surgery: 22.70 vs 29.0, P < 0.05; 12 mo after surgery: 15.5 vs 19.5, P = 0.01). The overall recurrence and metastasis rates were similar (4.3% and 11.4%, respectively).
CONCLUSION Colonic pouch anastomosis is a safe and effective procedure for colorectal reconstruction after low and ultralow rectal resections. Moreover, colonic pouch construction may provide better functional outcomes compared to straight anastomosis.
Collapse
Affiliation(s)
- Zhen-Zhou Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Yi-Dan Li
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Wang Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Ning-Hui Chai
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| |
Collapse
|
18
|
Kazi M, Bhamre R, DeSouza A, Ostwal V, Engineer R, Patel S, Sukumar V, Saklani A. Long-term oncological outcomes of the sphincter preserving total mesorectal excision with varying distal resection margins. J Surg Oncol 2021; 123:1784-1791. [PMID: 33751581 DOI: 10.1002/jso.26467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION A subcentimeter distal resection margin (DRM) appears to be acceptable for most patients, however, long-term follow up and specific subsets where DRM would influence recurrences have not been adequately investigated. METHODS A retrospective analysis of all sphincter-preserving resections for mid and low rectal cancers between July 2011 and May 2015 was performed. Extended total mesorectal excisions (TME) and patients with positive pathologic circumferential margins (CRM) were excluded. RESULTS Two hundred and thirty-six patients fit the inclusion criteria. DRM > 20 mm was obtained in 117 patients (49.6%), between 10 and 20 mm in 78 (33%) and <10 mm in 41 (17.4%) patients. Pathological DRM was positive in 4 patients (1.7%). Sixty-five recurrences occurred at a median follow up of 78.5 months. DRM did not influence any of the oncological outcomes. In a subset analysis of patients with poor pathological response to neoadjuvant radiation, that is, tumor regression grade > 3, DRM influenced disease-free survival (DFS) but not overall survival with a hazard ratio of 4.4 (p = 0.02). This was confirmed on multivariate regression analysis in this subgroup as well where pathological nodal status and DRM < 10 mm were independent predictors of DFS. CONCLUSIONS A subcentimeter DRM may be acceptable in most patients except those who have an inadequate response to neoadjuvant radiation.
Collapse
Affiliation(s)
- Mufaddal Kazi
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rahul Bhamre
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashwin DeSouza
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Swapnil Patel
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vivek Sukumar
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
19
|
Latest Advances in Intersphincteric Resection for Low Rectal Cancer. Gastroenterol Res Pract 2020; 2020:8928109. [PMID: 32765603 PMCID: PMC7387965 DOI: 10.1155/2020/8928109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.
Collapse
|
20
|
Ozawa H, Kotake K, Ike H, Sugihara K. Prognostic Impact of the Length of the Distal Resection Margin in Rectosigmoid Cancer: An Analysis of the JSCCR Database between 1995 and 2004. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:59-66. [PMID: 32346644 PMCID: PMC7186012 DOI: 10.23922/jarc.2019-013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/16/2020] [Indexed: 11/30/2022]
Abstract
Objectives The necessary and sufficient length of the distal resection margin (l-DRM) for rectosigmoid cancer remains controversial. This study evaluated the validity of the 3-cm l-DRM rule for rectosigmoid cancer in the Japanese classification of colorectal cancer. Methods We retrospectively reviewed 1,443 patients with cT3 and cT4 rectosigmoid cancer who underwent R0 resection in Japanese institutions between 1995 and 2004. We identified the optimal cutoff point of the l-DRM affecting overall survival (OS) rate using a multivariate Cox regression analysis model. Using this cutoff point, the patients were divided into two groups after balancing the potential confounding factors of the l-DRM using propensity score matching, and the OS rates of the two groups were compared. Results A multivariate Cox regression analysis model revealed that the l-DRM of 4 cm was the best cutoff point with the greatest impact on OS rate (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.00-1.84; P = 0.0452) and with the lowest Akaike information criterion value. In the matched cohort study, the OS rate of patients who had l-DRM of 4 cm or more was significantly higher than that of patients who had l-DRM < 4 cm (n = 402; 5-year OS rates, 87.6% vs. 80.3%, respectively; HR, 1.60; 95% CI, 1.09-2.31; P = 0.0136). Conclusions For cT3 and cT4 rectosigmoid cancer, l-DRM of 4 cm may be an appropriate landmark for a curative intent surgery, and we were unable to definitively confirm the validity of the Japanese 3-cm l-DRM rule.
Collapse
Affiliation(s)
- Heita Ozawa
- Department of Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | - Kenjiro Kotake
- Department of Gastroenterological Surgery, Sano City Hospital, Sano, Japan
| | - Hideyuki Ike
- Department of Surgery, Yokohama Hodogaya Central Hospital, Yokohama, Japan
| | | |
Collapse
|
21
|
Ding H, Li J, Chen Y, Yang Z, Peng Z, Liao X. Anal function and quality of life analysis after laparoscopic modified Parks for ultra-low rectal cancer patients. World J Surg Oncol 2020; 18:28. [PMID: 32013992 PMCID: PMC6998312 DOI: 10.1186/s12957-020-1801-7] [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: 12/05/2019] [Accepted: 01/21/2020] [Indexed: 02/08/2023] Open
Abstract
Background To assess postoperative anal function and quality of life of ultra-low rectal cancer patients treated by laparoscopic modified Parks surgery. Methods From February 2017 to March 2019, 114 patients with ultra-low rectal cancer above T2 were treated respectively with ultra-low anterior resection (Dixon), modified coloanal anastomosis (modified Parks), and Miles according to the preoperative stage and anastomotic position. The postoperative anal function and Fecal Incontinence Quality of Life Scale (FIQL) of each patient were collected and synthetically analyzed. Results Compared with the Dixon group, the postoperative anal function and FIQL in the Parks group were poor at the early stage. However, from 6 to 12 months after surgery, the scores of anal function and FIQL in the Parks group were similar to those in the Dixon group (P > 0.05). Compared with the Miles group, the FIQL of the two groups were similar in the early postoperative stage. However, with the passage of time, from 3 to 9 months after surgery, the four domains of FIQL in the Parks group were higher than those in the Miles group successively (P < 0.05). Conclusions Laparoscopic modified Parks is a safe, effective, and economical anus-preserving surgery. Although its early anal function and FIQL were poor, it could gradually recover to the similar level as Dixon. Moreover, it can save the anus and obtain a better postoperative quality of life for some patients who previously could only undergo Miles.
Collapse
Affiliation(s)
- Haibo Ding
- Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Jian Li
- Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| | - Yuxiang Chen
- School of Pharmaceutical Science, Central South University, 172 Tongzip Road, Changsha, 410013, Hunan, China
| | - Zhi Yang
- Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Zha Peng
- Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Xin Liao
- Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| |
Collapse
|
22
|
Kosuge M, Eto K, Sasaki S, Sugano H, Yatabe S, Takeda Y, Ito D, Ohkuma M, Yanaga K. Clinical factors affecting the distal margin in rectal cancer surgery. Surg Today 2020; 50:743-748. [PMID: 31974754 DOI: 10.1007/s00595-020-01959-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 12/12/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE In rectal cancer surgery, an insufficient distal margin (DM) is associated with a high risk of local recurrence, whereas an excessive DM will cause low anterior resection syndrome, impairing quality of life. This study aimed to identify the factors that affect the distance between the colorectal resection site and the tumor to optimize achieving the correct DM. METHODS The subjects of this study were 219 patients who underwent resection for primary rectal cancer in our department between January 2006 and July 2014. According to Japanese guidelines, DM (rDM) was based on the tumor location, but the pathological DM (pDM) was measured from surgical specimens. The patients were divided into two groups: the pDM-less-than-rDM group (pDM < rDM) and the pDM-greater-or-equal-to-rDM group (pDM ≥ DM). The factors associated with the DM in the two groups were compared. RESULTS In the pDM < rDM group, the tumor distance from the anal verge was shorter (p = 0.001) and significantly more patients underwent laparotomy (p = 0.047). CONCLUSION The DM tended to be shorter than that planned by the surgeon in patients with lower rectal cancers and those treated by laparotomy,; therefore, when performing rectal resection, care must be taken to ensure that the pDM is not shorter than the rDM.
Collapse
Affiliation(s)
- Makoto Kosuge
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shigemasa Sasaki
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroshi Sugano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Saori Yatabe
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yasuhiro Takeda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Daisuke Ito
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masahisa Ohkuma
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| |
Collapse
|
23
|
Janavikula Sankaran R, Kollapalayam Raman D, Raju P, Syed A, Rajkumar A, Aluru JR, Nazeer N, Rajkumar S, Kj J. Laparoscopic Ultra Low Anterior Resection: Single Center, 6-Year Study. J Laparoendosc Adv Surg Tech A 2020; 30:284-291. [PMID: 31976812 DOI: 10.1089/lap.2019.0652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: This study represents a prospective analysis of a series of laparoscopic ultra low anterior resection (ULAR) done at a laparoscopic surgical center to assess the surgical outcome, oncological efficacy, and quality of life after surgery. Methods: Over a period of 6 years (2013-2018), 43 patients aged between 40 and 68 years, with very low rectal cancers (3-6 cm from the anal verge), within T3N1M0 stage, assessed by positron emission tomography-computed tomography and pelvic magnetic resonance imaging, underwent neoadjuvant chemoradiotherapy (nCRT) followed by laparoscopic ULAR and simultaneous diversion ileostomy. Results: The overall complication rate was low and there was an overall leak rate of 9.3% with a radiological leak (Grade A) in 3 of the 43 patients (7%), but only 1 (2.3%) patient required a local lavage and a resuturing for secondary hemorrhage. Recurrence was seen in 2/43 (4.7%), one of whom had a conversion to abdominoperineal resection. The other had distant metastasis and refused further treatment. The functional outcome is assessed in 41 (95.3%) patients by low anterior resection syndrome (LARS) score and a reasonable quality of life with major LARS was seen in only 7.3% of the patients at a follow-up ranging from 1 to 6 years. Conclusion: The nCRT followed by laparoscopic ULAR is a feasible option for operable very low rectal cancers and is associated with minimal postoperative events, a low local recurrence and less incidence of LARS.
Collapse
Affiliation(s)
| | | | | | - Akbar Syed
- Lifeline Hospitals, Kilpauk, Chennai, India
| | | | | | | | | | | |
Collapse
|
24
|
Can a Local Drainage Salvage a Failed Colorectal or Coloanal Anastomosis? A Prospective Cohort of 54 Patients. Dis Colon Rectum 2020; 63:93-100. [PMID: 31804271 DOI: 10.1097/dcr.0000000000001516] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Local drainages can be used to manage leakage in select patients without peritonitis. OBJECTIVE The aim of this study was to evaluate the efficacy of drainage procedures in maintaining a primary low anastomosis after anastomotic leakage. DESIGN A retrospective observational study was performed on a prospectively maintained database. SETTINGS The study was performed between 2014 and 2017 in a tertiary referral center. PATIENTS Patients undergoing rectal resections with either a colorectal or coloanal anastomosis with diverting stoma were identified. Anastomotic leakages requiring a radiological or transanal drainage without peritonitis were included. MAIN OUTCOME MEASURES The primary outcome was the maintenance of the primary anastomosis after local drainage of an anastomotic leakage and stoma reversal. RESULTS A low anastomosis for rectal cancer with diverting stoma was performed in 326 patients. A total of 77 anastomotic leakages (24%) occurred, of which, 6 (8%) required abdominal surgery, 17 (22%) were treated conservatively (medical management), and 54 (70%) were managed by drainage. Surgical transanal drainage was performed in 21 patients (39%), with radiologic drainage procedures performed in 33 patients (61%). The median interval between surgery and drainage was 13 days (range, 9-21 d). Five patients (9%) required emergency abdominal surgery. Twenty-seven patients (50%) did not require any additional intervention after drainage procedure, whereas 21 patients (39%) underwent redo anastomotic surgery. Forty-three patients (80%) had no stoma at the end of follow-up. Failure to maintain the primary anastomosis after local drainage was associated with increased age (p = 0.04), a pelvic per-operative drainage (p = 0.05), a drainage duration >10 days (p = 0.002), the time between surgery and drainage >15 days (p = 0.03), a side-to-end or J-pouch anastomosis (p = 0.04), and surgical transanal drainage (p = 0.03). LIMITATIONS The small sample size of the study was the main limitation. CONCLUSIONS Local drainage procedures maintained primary anastomosis in 50% of cases after an anastomotic leakage. See Video Abstract at http://links.lww.com/DCR/B57. ¿PUEDE UN DRENAJE LOCAL SALVAR UNA ANASTOMOSIS COLORRECTAL O COLOANAL FALLIDA? UNA COHORTE PROSPECTIVO DE 54 PACIENTES: Los drenajes locales se pueden utilizar para controlar las fugas en pacientes seleccionados sin peritonitis.El objetivo de este estudio fue evaluar la eficacia de los procedimientos de drenaje, para mantener una anastomosis primaria baja, después de una fuga anastomótica.Se realizó un estudio observacional retrospectivo en una base de datos mantenida prospectivamente.El estudio se realizó entre 2014-2017, en un centro de referencia terciaria.Se identificaron pacientes sometidos a resecciones rectales con anastomosis colorrectal o coloanal y estoma de derivación. Se incluyeron fugas anastomóticas sin peritonitis, que requirieron drenaje radiológico o transanal.El resultado primario fue el mantenimiento de la anastomosis primaria, después del drenaje local de una fuga anastomótica y la reversión del estoma.Se realizó una anastomosis baja para cáncer rectal con estoma derivativo en 326 pacientes. Se produjeron 77 (24%) fugas anastomóticas, de las cuales 6 (8%) requirieron cirugía abdominal, 17 (22%) fueron tratadas de forma conservadora (tratamiento médico) y 54 (70%) fueron manejadas por drenaje. Se realizó drenaje transanal en 21 pacientes (39%) y procedimientos de drenaje radiológico en 33 pacientes (61%). La mediana del intervalo entre la cirugía y el drenaje fue de 13 días [9-21]. 5 (9%) pacientes requirieron cirugía abdominal de emergencia. Veintisiete (50%) pacientes no requirieron ninguna intervención adicional después del procedimiento de drenaje, mientras que 21 pacientes (39%) se sometieron a una reparación quirúrgica anastomótica. 43 pacientes (80%) no tuvieron estoma al final del seguimiento. El fracaso para mantener la anastomosis primaria después del drenaje local, se asoció con un aumento de la edad (p = 0.04), un drenaje pélvico preoperatorio (p = 0.05), una duración del drenaje >10 días (p = 0.002), el tiempo entre la cirugía y el drenaje >15 días (p = 0.03), anastomosis termino lateral o bolsa en J (p = 0.04) y drenaje quirúrgico transanal (p = 0.03).El pequeño tamaño de la muestra del estudio fue la principal limitación.Después de la fuga anastomótica, los procedimientos del drenaje local conservaron la anastomosis primaria en el 50% de los casos. Vea el Resumen del Video en http://links.lww.com/DCR/B57.
Collapse
|
25
|
The clinical significance of distal spread differs according to the primary tumor location in rectal cancer. Surg Today 2019; 50:360-368. [DOI: 10.1007/s00595-019-01882-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022]
|
26
|
Bhamre R, Mitra A, Tamankar A, Desouza A, Saklani A. Impact of Length of Distal Margin on Outcomes Following Sphincter Preserving Surgery for Middle and Lower Third Rectal Cancers. Indian J Surg Oncol 2019; 10:335-341. [PMID: 31168259 PMCID: PMC6527665 DOI: 10.1007/s13193-019-00888-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/25/2019] [Indexed: 02/06/2023] Open
Abstract
Outcomes of sphincter preserving surgery for distal rectal cancers improve with clear circumferential resection and distal resection margin. However, the extent of distal resection margin after a complete mesorectal excision is often a cause for debate. We evaluated the outcome of middle and lower third rectal cancer patients undergoing sphincter preservation with variable distal resection margin at our center. Patients with biopsy-proven rectal adenocarcinoma within 10 cm from anal verge undergoing sphincter preserving resections were included. Patients with positive circumferential resection margin were excluded. Patients were divided into three groups based on the extent of distal resection margin (< 6 mm, 6-10 mm, > 10 mm) and oncological outcomes were compared. The median age of 242 patients was 50 years and 44 (18.2%) were high-grade tumors. Preoperative chemoradiation was used in 185 (75.2%) patients. Median distal resection margin was 20 mm. Patients in < 10 mm group had a significantly higher proportion of lower third (68.3% vs 39.8%, p = 0.004) and chemoradiation-treated tumors (85.4 vs 74.6%, p = 0.001). A significantly higher percentage required an intersphincteric resection in the < 10 mm group (53.7% vs 14.4%, p = 0.0001). Significantly higher percentage tumors were pT3 in > 10 mm group (45.3% vs. 31.7%) (p = 0.05). The median follow-up was 23 months. There was no difference in the overall, loco-regional, and distant recurrence rates between the three groups. A subcentimeter distal resection margin does not influence loco-regional or distant recurrence rates following sphincter preserving surgery for middle and lower third rectal adenocarcinoma.
Collapse
Affiliation(s)
- Rahul Bhamre
- 1Colorectal Service, Department of Surgical oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012 India
| | - Abhishek Mitra
- GI and HPB Service, Department of Surgical Oncology, National Cancer Institute, Nagpur, India
| | - Anup Tamankar
- 1Colorectal Service, Department of Surgical oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012 India
| | - Ashwin Desouza
- 1Colorectal Service, Department of Surgical oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012 India
| | - Avanish Saklani
- 1Colorectal Service, Department of Surgical oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012 India
| |
Collapse
|
27
|
Kondo A, Tsukada Y, Kojima M, Nishizawa Y, Sasaki T, Suzuki Y, Ito M. Effect of preoperative chemotherapy on distal spread of low rectal cancer located close to the anus. Int J Colorectal Dis 2018; 33:1685-1693. [PMID: 30215109 DOI: 10.1007/s00384-018-3159-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to clarify the frequency of distal spread and the optimal distal margin after preoperative chemotherapy for advanced low rectal cancer. METHODS The study included patients with advanced lower rectal cancer who received preoperative chemotherapy and underwent surgery during 2012-2015. We investigated the distal spread of tumor cells, defined as the distal distance from the intramucosal distal tumor edge to the farthest tumor cells located under the submucosal layer. Clinical characteristics were compared for distal spreads ≥ 10 and < 10 mm, and risk factors for distal spread ≥ 10 mm were investigated. RESULTS Of the 71 patients, 42 (59%) showed distal spread. Distal spreads of 1-9, 10-19, and ≥ 20 mm were observed in 27 (38%), 11 (15%), and 4 (6%) patients, respectively. Multivariate analysis revealed two independent risk factors for distal spread ≥ 10 mm after preoperative chemotherapy. The first risk factor is the presence of different therapeutic effects between the mucosal and deeper layers (meaning that superficial tumor shrinkage was evident on colonoscopy, but little tumor shrinkage was evident on magnetic resonance imaging) (odds ratio, 11.6; 95% CI, 2.22-61.3). The second risk factor is poorly differentiated or mucinous adenocarcinoma (odds ratio, 8.86; 95% CI, 1.58-49.9). CONCLUSION A distal margin of 20 mm is required (10 mm is insufficient) for advanced lower rectal cancer patients who receive preoperative chemotherapy followed by surgery. Independent risk factors for distal spread ≥ 10 mm include (1) the presence of different therapeutic effects between mucosal and deeper layers and (2) poorly differentiated or mucinous adenocarcinomas.
Collapse
Affiliation(s)
- Akihiro Kondo
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Motohiro Kojima
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan.
| |
Collapse
|
28
|
Real-time in vivo optical biopsy using confocal laser endomicroscopy to evaluate distal margin in situ and determine surgical procedure in low rectal cancer. Surg Endosc 2018; 33:2332-2338. [DOI: 10.1007/s00464-018-6519-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 10/11/2018] [Indexed: 12/27/2022]
|
29
|
Raut CP. Tumor Biological Aspects of Epithelial versus Mesenchymal Tumors of the Gastrointestinal Tract. Visc Med 2018; 34:342-346. [PMID: 30498700 PMCID: PMC6257144 DOI: 10.1159/000493474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
One of the holy grails of cancer surgery for surgical oncologists is to perform a macroscopically complete resection of the affected organ or site with negative microscopic margins. The surgical oncologist must also be mindful of what constitutes appropriately-sized negative margins. However, what is necessary, based on the best available evidence, can vary considerably for different malignancies arising within the same organ. This review compares two different gastric and rectal malignancies, one each of epithelial and of mesenchymal origin. Data supporting extent of margins will be reviewed, illustrating the importance of knowing the histologic diagnosis prior to surgery to provide proper oncologic care.
Collapse
Affiliation(s)
- Chandrajit P. Raut
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
30
|
Park IJ, Kim JC. Intersphincteric Resection for Patients With Low-Lying Rectal Cancer: Oncological and Functional Outcomes. Ann Coloproctol 2018; 34:167-174. [PMID: 30208679 PMCID: PMC6140365 DOI: 10.3393/ac.2018.08.02] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022] Open
Abstract
The aim of this review is to evaluate the outcomes after an intersphincteric resection (ISR) for patients with low-lying rectal cancer. Reports published in the literature regarding surgical, oncological, and functional outcomes of an ISR were reviewed. The morbidity after an ISR was 7.7%–32%, and anastomotic leakage was the most common adverse event. Local recurrence rates ranged from 0% to 12%, 5-year overall survival rates ranged from 62% to 92%, and rates of major incontinence ranged from 0% to 25.8% after an ISR. An ISR is a safe procedure for sphincter-saving rectal surgery in patients with very low rectal cancer; it does not compromise the oncological outcomes of the resection and is a valuable alternative to an abdominoperineal resection. While the functional outcomes after an ISR were found to be acceptable, the long-term functional outcome and quality of life still require careful investigation. ISRs have been performed with surgical and oncologic safety on patients with low-lying rectal cancer. However, patients must be selected very carefully for an ISR, considering the associated functional derangement and the limited extent of the resection.
Collapse
Affiliation(s)
- In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
31
|
Khararjian A, Mathew P, Choudhary A, Baras A. Cost Effectiveness of Intraoperative Gross Examination in Colorectal Resections: A Retrospective Review of 200 Consecutive Cases. Arch Pathol Lab Med 2018; 142:1403-1406. [PMID: 29902068 DOI: 10.5858/arpa.2017-0201-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Intraoperative pathology consultation is an important tool for many surgical procedures and is deemed appropriate when the pathology result immediately alters surgical management. OBJECTIVE.— To evaluate the utility of intraoperative gross examinations of colorectal resections and to better understand the associated costs. DESIGN.— The pathology database of our institution was searched for colorectal resections for primary disease, and those cases were separated into 3 categories: frozen section performed, intraoperative gross examination performed, and no intraoperative consultation. We reviewed 270 cases during a 15-month period. RESULTS.— Of the 270 cases, 200 (74.1%) had an intraoperative gross examination. In 34 of the 200 cases (17%), additional specimens were taken and, therefore, required operative note review to ascertain whether the additional specimens taken were based on the findings from the intraoperative gross examination. After reviewing the operative notes for those 34 cases, none (0%) were a result of the gross findings reported. The average associated time for intraoperative gross examinations was 27.67 minutes (including transport). The billable costs exceeded $7000 during the study period, and the cost of the pathology assistant's time per case was $22.10. CONCLUSIONS.— Our study demonstrates that no change in surgical management was a result of gross examination of colorectal resection specimens and that the associated costs were significant. Decreasing unnecessary consultations will directly save the health care system money by eliminating billable services and will also increase the efficiency of the pathology department by reducing the opportunity costs for the time of the pathologist and the pathology staff.
Collapse
Affiliation(s)
| | | | | | - Alexander Baras
- From the Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland (Drs Khararjian and Baras and Ms Choudhary); and the Department of Surgery, University of Arizona College of Medicine, Tucson (Dr Mathew)
| |
Collapse
|
32
|
A Distal Resection Margin of ≤1 mm and Rectal Cancer Recurrence After Sphincter-Preserving Surgery: The Role of a Positive Distal Margin in Rectal Cancer Surgery. Dis Colon Rectum 2017; 60:1175-1183. [PMID: 28991082 DOI: 10.1097/dcr.0000000000000900] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is little information about the prognostic value of a microscopically positive distal margin in patients who have rectal cancer. OBJECTIVE We aimed to investigate the influence of a distal margin of ≤1 mm on oncologic outcomes after sphincter-preserving resection for rectal cancer. DESIGN This is a retrospective cohort study. SETTINGS The study was conducted at 2 hospitals. PATIENTS A total of 6574 patients underwent anterior resection for rectal cancer from January 1999 to December 2014; 97 (1.5%) patients with a distal margin of ≤1 mm were included in this study. For comparative analyses, patients were matched with 194 patients with a negative distal margin (>1 mm) according to sex, age, BMI, ASA score, neoadjuvant treatment, tumor location, and stage. MAIN OUTCOME MEASURES The oncologic outcomes of the 2 groups were compared. RESULTS Perineural and lymphovascular invasion rates were significantly higher in patients with a positive distal margin (54.6% vs 28.9%; 67.0% vs 42.8%; both p < 0.001) compared with to patients with negative distal margin. Comparison between microscopically positive and negative distal margin showed worse oncologic outcomes in patients with a microscopically positive distal margin, including 5-year local recurrence rate (24.1% vs 12.0%, p = 0.005); 5-year distant recurrence rate (35.5% vs 20.2%, p = 0.011); 5-year disease-free survival (45.5% vs 69.5%, p < 0.001); and 5-year OS (69.2% vs 79.7%, p = 0.004). Among the 97 patients with a microscopically positive distal margin, the 5-year disease-free survival rate was higher in patients who received adjuvant therapy (52.0% vs 30.7%, p = 0.089). LIMITATIONS This is a retrospective study; bias may exist. CONCLUSIONS A distal margin of 1 mm is associated with worse oncologic results. Our data indicate the importance of achieving a clear distal margin in the surgical treatment of rectal cancer. Adjuvant therapy should be used in these patients to reduce recurrence. See Video Abstract at http://links.lww.com/DCR/A408.
Collapse
|
33
|
Allaix ME, Giraudo G, Ferrarese A, Arezzo A, Rebecchi F, Morino M. 10-Year Oncologic Outcomes After Laparoscopic or Open Total Mesorectal Excision for Rectal Cancer. World J Surg 2017; 40:3052-3062. [PMID: 27417110 DOI: 10.1007/s00268-016-3631-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Only few studies have compared laparoscopic total mesorectal excision (LTME) and open total mesorectal excision (OTME) for rectal cancer with follow-up longer than 5 years. The aim of this study was to compare 10-year oncologic outcomes after LTME and OTME for nonmetastatic rectal cancer. METHODS We conducted a retrospective analysis of a prospective database of rectal cancer patients undergoing LTME or OTME. Statistical analyses were performed on an ''intention-to-treat'' basis and by actual treatment. Overall survival (OS) and disease-free survival (DFS) were compared by using the Kaplan-Meier method. A multivariable analysis was performed to identify predictors of poor survival. RESULTS Between April 1994 and August 2005, a total of 153 LTME patients and 154 OTME patients were included. Similarly, 10-year OS and DFS after LTME and OTME were observed: 76.8 versus 70.6 % (P = 0.138) and 69.1 versus 67.6 % (P = 0.508), respectively. Conversion to OTME did not adversely affect OS and DFS. Stage-by-stage comparison showed no significant differences between LTME and OTME. No significant differences were observed in local recurrence rates after LTME and OTME (6.5 vs. 7.8 %, P = 0.837). Median time until local recurrence was 24.5 (range, 12-56) months after LTME and 22 (6-64) months after OTME (P = 0.777). Poor tumor differentiation, lymphovascular invasion, and a lymph node ratio of 0.25 or more were the independent predictors of poorer OS and DFS. CONCLUSION This retrospective study with long follow-up did not show significant differences between the two groups in OS and DFS.
Collapse
Affiliation(s)
- Marco E Allaix
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy.
| | - Giuseppe Giraudo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Alessia Ferrarese
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| |
Collapse
|
34
|
Zhu HB, Wang L, Li ZY, Li XT, Zhang XY, Sun YS. Sphincter-preserving surgery for low-middle rectal cancer: Can we predict feasibility with high-resolution magnetic resonance imaging? Medicine (Baltimore) 2017; 96:e7418. [PMID: 28723750 PMCID: PMC5521890 DOI: 10.1097/md.0000000000007418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The study proposed to evaluate the feasibility of predicting sphincter-sparing surgery (SSS) preoperatively in low-middle rectal cancer by using magnetic resonance (MR).The study included both retrospective and prospective design. In the retrospective design, the distance from lower edge of tumor to upper margin of the internal sphincter (Dis1) and distance to anal verge (Dis2) were measured on MR, the distance to anal verge recorded by colonoscopy (Dis3) and digital rectal examination (Dis4) were also obtained. ROC analysis was conducted and cut-off value was determined with overall and stratified analysis. The prospective part was designed to validate the predictive capability of the optimal distance.The retrospective design included 278 patients with middle or lower rectal adenocarcinoma, the prospective design included 106 patients with neoadjuvant therapies. The primary outcome was the actual surgical method and pathological distal resection margin. Dis1 obtained from MRI presented better performance than other distances in determining the surgical approach, with AUC of 0.997 (95% CI, 0.934-1.000). Dis1 was selected as the optimal distance and a cut-off value of 2 cm was determined. Dis1 and the cut-off value were also validated in the prospective sample, with AUC of 0.996 (95% CI, 0.989-1.000) and an overall accuracy of 99.1%.MR-based distance from lower edge of tumor to upper margin of the internal sphincter could be used to help the surgeons to predict the feasibility of SSS preoperatively.
Collapse
Affiliation(s)
- Hai-Bin Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Colorectal Surgery
| | - Zi-Yu Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Xiao-Ting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| | - Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| |
Collapse
|
35
|
Shirouzu K, Murakami N, Akagi Y. Intersphincteric resection for very low rectal cancer: A review of the updated literature. Ann Gastroenterol Surg 2017; 1:24-32. [PMID: 29863144 PMCID: PMC5881339 DOI: 10.1002/ags3.12003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/16/2017] [Indexed: 12/15/2022] Open
Abstract
Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.
Collapse
Affiliation(s)
- Kazuo Shirouzu
- Department of Gastrointestinal Surgery Japan Community Health care Organization Kurume General Hospital Kurume Japan
| | - Naotaka Murakami
- Department of Gastrointestinal Surgery Japan Community Health care Organization Kurume General Hospital Kurume Japan
| | - Yoshito Akagi
- Department of Surgery Kurume University Faculty of Medicine Kurume Japan
| |
Collapse
|
36
|
Kuo LJ, Ngu JCY, Huang YJ, Lin YK, Chen CC, Tong YS, Huang SC, Hu CC, Tan SH. Anorectal complications after robotic intersphincteric resection for low rectal cancer. Surg Endosc 2017; 31:4466-4471. [PMID: 28374259 DOI: 10.1007/s00464-017-5499-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 03/08/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Robotic intersphincteric resection (ISR) has been introduced for sphincter-preservation in the treatment of low rectal cancer. However, many patients experience anorectal symptoms and defecatory dysfunction after ISR. This study aims to evaluate the anorectal complications that develop after ISR. METHODS The medical records of 108 patients who underwent robotic ISR at Taipei Medical University Hospital, Taipei, Taiwan between December 2011 and June 2016 were retrospectively reviewed. Photographic records of perineal conditions were documented at the following time intervals after surgery: 1 day, 2 weeks, 1, 2, 3 and 6 months. Clinical outcomes and treatment results were analysed. RESULTS Eighty-five patients (78.7%) developed edematous hemorrhoids after surgery. These subsided at a median of 56 days after operation (range 23-89 days). Forty-six patients (42.6%) were found to have anal stenosis requiring anal dilatation. Sixteen patients (14.8%) had neorectal mucosal prolapse, which was noted to occur at an average of 98 days after surgery (range 41-162 days). Multivariate analysis showed that the occurrence of edematous hemorrhoids was associated with operating time (P = 0.043), and male gender was a significant risk factor for anal stenosis (P = 0.007). CONCLUSIONS This is the first study reporting on the clinical outcomes of anorectal status after robotic ISR. Further studies are needed to assess the long-term effects of these anorectal complications.
Collapse
Affiliation(s)
- Li-Jen Kuo
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, 252 Wuxing Street, Sinyi District, Taipei, 11031, Taiwan.
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | | | - Yan-Jiun Huang
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, 252 Wuxing Street, Sinyi District, Taipei, 11031, Taiwan
- The Ph.D. Program for Translational Medicine, College of Medical Science and Technology, Taipei Medical University and Academia Sinica, Taipei, Taiwan
| | - Yen-Kuang Lin
- Biostatistics and Research Consultation Center, Taipei Medical University, Taipei, Taiwan
| | - Chia-Che Chen
- Division of Acute Care Surgery and Traumatology, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yiu-Shun Tong
- Division of Acute Care Surgery and Traumatology, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Szu-Chia Huang
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chia-Chen Hu
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, 252 Wuxing Street, Sinyi District, Taipei, 11031, Taiwan
| | - Shu-Hwa Tan
- Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
| |
Collapse
|
37
|
Gérard JP, André T, Bibeau F, Conroy T, Legoux JL, Portier G, Bosset JF, Cadiot G, Bouché O, Bedenne L. Rectal cancer: French Intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Dig Liver Dis 2017; 49:359-367. [PMID: 28179091 DOI: 10.1016/j.dld.2017.01.152] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This document is a summary of the French Intergroup guidelines regarding the management of rectal adenocarcinoma published in February 2016. METHOD This collaborative work, under the auspices of most of the French medical societies involved in the management of rectal cancer, is based on the previous guidelines published in 2013. Recommendations are graded into 3 categories according to the level of evidence of data found in the literature. RESULTS In agreement with the ESMO guidelines (2013), non-metastatic rectal cancers have been stratified in 4 risk groups according to endoscopy, MRI or endorectal-ultrasonography. Locally-advanced tumors are limited to groups 3 and 4 (T3≥4cm or T3c-d or N1-2 or T4). These tumors are usually treated using neoadjuvant treatment and total proctectomy (TME). Adjuvant treatment depends on the pathological findings. Very early (group 1) or early (group 2) tumors are managed mainly by surgery, and organ preservation may be an option in selected cases. For metastatic tumors, the recommendations are based on less robust evidence and chemotherapy plays a major role. CONCLUSION Such recommendations are constantly being optimized and each individual case must be discussed within a Multi-Disciplinary Team.
Collapse
|
38
|
Kang DW, Kwak HD, Sung NS, Yang IS, Baek SJ, Kwak JM, Kim J, Kim SH. Oncologic outcomes in rectal cancer patients with a ≤1-cm distal resection margin. Int J Colorectal Dis 2017; 32:325-332. [PMID: 27900522 DOI: 10.1007/s00384-016-2708-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Recently, common application of sphincter-saving resection in rectal cancer has led to acceptance of a 1-cm distal resection margin (DRM). The aim of this study was to evaluate oncologic outcomes of a DRM ≤1 cm in sphincter-saving resection for rectal cancer. The outcomes of a DRM ≤0.5 cm was also evaluated. METHODS We reviewed prospectively collected data from 415 patients who underwent sphincter-saving resection for mid and low rectal cancer between September 2006 and December 2012 at Korea University Anam Hospital. Patients were divided into two groups according to DRM measured in a formalin fixed specimen: ≤1 cm (n = 132) and >1 cm (n = 283). The DRM ≤1 cm group was divided into two subgroups: ≤0.5 cm (n = 45) and >0.5, ≤1 cm (n = 87). RESULTS Median follow-up periods were 47.2 months. The 5-year local recurrence rate was 8.8% in the DRM ≤1 cm group and 8.5% in the DRM >1 cm group (p = 0.630). The 5-year disease-free survival rate was 75.1 and 76.3% (p = 0.895), and the 5-year overall survival rate was 82.6 and 85.9% (p = 0.401), respectively. In subanalysis of the DRM ≤1 cm group, there was also no significant difference in the local recurrence and survival. CONCLUSIONS There was no significant difference in local recurrence and survival based on DRM length. We found that DRM length less than 1 cm was not a prognostic factor for local recurrence or survival.
Collapse
Affiliation(s)
- Dong Woo Kang
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Han Deok Kwak
- Division of Colorectal Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, South Korea
| | - Nak Song Sung
- Division of Colorectal Surgery, Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, South Korea
| | - In Soo Yang
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Se Jin Baek
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Jung Myun Kwak
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Seon Hahn Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea.
| |
Collapse
|
39
|
Imran J, Yao JJ, Madni T, Huerta S. Current Concepts on the Distal Margin of Resection of Rectal Cancer Tumors after Neoadjuvant Chemoradiation. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0343-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
40
|
Chen PC, Lee JC. Treatment of locally advanced low rectal cancer. FORMOSAN JOURNAL OF SURGERY 2016. [DOI: 10.1016/j.fjs.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
41
|
Grosek J, Velenik V, Edhemovic I, Omejc M. The Influence of the Distal Resection Margin Length on Local Recurrence and long- term Survival in Patients with Rectal Cancer after Chemoradiotherapy and Sphincter- Preserving Rectal Resection. Radiol Oncol 2016; 51:169-177. [PMID: 28740452 PMCID: PMC5514657 DOI: 10.1515/raon-2016-0030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 04/10/2016] [Indexed: 12/28/2022] Open
Abstract
Background Low recurrence rates and long term survival are the main therapeutic goals of rectal cancer surgery. Complete, margin- negative resection confers the greatest chance for a cure. The aim of our study was to determine whether the length of the distal resection margin was associated with local recurrence rate and long- term survival. Patients and methods One hundred and nine patients, who underwent sphincter-preserving resection for locally advanced rectal cancer after preoperative chemoradiotherapy between 2006 and 2010 in two tertiary referral centres were included in the study. Distal resection margin lengths were measured on formalin-fixed, pinned specimens. Characteristics of patients with distal resection margin < 8 mm (Group I, n = 27), 8–20 mm (Group II, n = 31) and > 20 mm (Group III, n = 51) were retrospectively analysed and compared. Median (range) follow-up time in Group I was 89 (51–111), in Group II 83 (57–111) and in Group III 80 (45–116) months (p = 0.326), respectively. Results Univariate survival analysis showed that distal resection margin length was not statistically significantly associated with overall survival or local recurrence rate (p > 0.05). In a multiple Cox regression analysis, after adjusting for pathologic T and N stage (yT, yN), distal resection margin length was still not statistically significantly associated with overall survival. Conclusions Our study shows that close distal resection margins can be accepted as oncologically safe for sphincter-preserving rectal resections after preoperative chemoradiotherapy.
Collapse
Affiliation(s)
- Jan Grosek
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vaneja Velenik
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Ibrahim Edhemovic
- Department of Surgery, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Mirko Omejc
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
42
|
Mukkai Krishnamurty D, Wise PE. Importance of surgical margins in rectal cancer. J Surg Oncol 2016; 113:323-32. [DOI: 10.1002/jso.24136] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Devi Mukkai Krishnamurty
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
| | - Paul E. Wise
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
| |
Collapse
|
43
|
Feroci F, Vannucchi A, Bianchi PP, Cantafio S, Garzi A, Formisano G, Scatizzi M. Total mesorectal excision for mid and low rectal cancer: Laparoscopic vs robotic surgery. World J Gastroenterol 2016; 22:3602-3610. [PMID: 27053852 PMCID: PMC4814646 DOI: 10.3748/wjg.v22.i13.3602] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/27/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.
METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision (TME) with curative intent between January 2008 and December 2014 (robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage I-III disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.
RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME (L-TME) and 342 min for robotic TME (R-TME) (P < 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. The patients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients (8 d for L-TME and 6 d for R-TME, P < 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group (18 for R-TME, 11 for L-TME, P < 0.001) and a shorter distal resection margin for laparoscopic patients (1.5 cm for L-TME, 2.5 cm for R-TME, P < 0.001). The three-year overall survival and disease-free survival rates were similar between groups.
CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.
Collapse
|
44
|
Hav M, Libbrecht L, Ferdinande L, Geboes K, Pattyn P, Cuvelier CA. Pathologic Assessment of Rectal Carcinoma after Neoadjuvant Radio(chemo)therapy: Prognostic Implications. BIOMED RESEARCH INTERNATIONAL 2015; 2015:574540. [PMID: 26509160 PMCID: PMC4609786 DOI: 10.1155/2015/574540] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 06/14/2015] [Indexed: 12/21/2022]
Abstract
Neoadjuvant radio(chemo)therapy is increasingly used in rectal cancer and induces a number of morphologic changes that affect prognostication after curative surgery, thereby creating new challenges for surgical pathologists, particularly in evaluating morphologic changes and tumour response to preoperative treatment. Surgical pathologists play an important role in determining the many facets of rectal carcinoma patient care after neoadjuvant treatment. These range from proper handling of macroscopic specimens to accurate microscopic evaluation of pathological features associated with patients' prognosis. This review presents the well-established pathological prognostic indicators and discusses challenging features in order to provide both surgical pathologists and treating physicians with a checklist that is useful in a neoadjuvant setting.
Collapse
Affiliation(s)
- Monirath Hav
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia ; Department of Pathology, Ghent University Hospital, 9000 Gent, Belgium
| | - Louis Libbrecht
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia
| | - Liesbeth Ferdinande
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia
| | - Karen Geboes
- Department of Gastrointestinal Oncology, Ghent University Hospital, 9000 Gent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, 9000 Gent, Belgium
| | - Claude A Cuvelier
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia
| |
Collapse
|
45
|
Wieghard NE, Hart KD, Herzig DO, Lu KC, Tsikitis VL. Psychiatric Illness is a Disparity in the Surgical Management of Rectal Cancer. Ann Surg Oncol 2015; 22 Suppl 3:S573-9. [PMID: 26362049 DOI: 10.1245/s10434-015-4791-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Psychiatric disorders are common in the US and represent a major health disparity but little is known about their impact on surgical management and outcomes in cancer. OBJECTIVE The aim of this study was to determine whether rectal cancer patients with psychiatric diagnoses have fewer sphincter-preserving procedures and higher postoperative complications. METHODS Overall, 23,914 patients from the Nationwide Inpatient Sample (NIS) who underwent surgery for rectal cancer from 2004 to 2011 were identified. Patients with comorbid common psychiatric diagnoses were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes. Main outcomes were measured by operation performed, length of stay (LOS), postoperative complications, and discharge disposition. RESULTS Twenty percent of patients had a psychiatric diagnosis, with substance use being the most common psychiatric disorder (63 %). Patients with psychiatric diagnoses were more likely to be younger, White, have lower income, and have Medicaid insurance (p < 0.001) than those without. In a logistic regression model, patients with any psychiatric diagnosis were less likely to have sphincter-sparing surgery, controlling for patient sociodemographics, Charlson score, hospital procedure volume, and year (odds ratio 0.77; 95 % CI 0.72-0.83). LOS and postoperative complications were similar among the cohorts. Patients with psychiatric disorders were more likely to have home health care at discharge (p < 0.001). CONCLUSIONS Fewer sphincter-sparing procedures were performed on rectal cancer patients with psychiatric diagnoses. However, no significant differences in postoperative complications were observed.
Collapse
Affiliation(s)
- Nicole E Wieghard
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Kyle D Hart
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Daniel O Herzig
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Kim C Lu
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - V Liana Tsikitis
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA.
| |
Collapse
|
46
|
Surgeon perspectives on the use and effects of neoadjuvant chemoradiation in the treatment of rectal cancer: a comprehensive review of the literature. Langenbecks Arch Surg 2015; 400:661-73. [PMID: 26250144 DOI: 10.1007/s00423-015-1328-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite screening initiatives, rectal cancer remains one of the most prevalent malignancies diagnosed in patients worldwide with a high mortality. The introduction of neoadjuvant therapy has resulted in a paradigm shift in the treatment and outcomes of rectal cancer. Surgeons play an intricate role in the pre-operative, operative, and post-operative management of these patients. PURPOSE The purpose of this comprehensive literature review was to summarize the evolution of the use chemotherapy and radiation and the process of differentiation into specific neoadjuvant chemoradiation protocols in the treatment of locally advanced rectal cancer. This will provide a concise summary for practicing surgeons of the current evidence for neoadjuvant chemoradiation as well as the various implications of therapy on operative outcomes. CONCLUSION The initial benefit of adjuvant therapy in the treatment of rectal cancer patients became evident with prospective studies demonstrating improvements in various oncologic survival outcomes. Due to the improved compliance and reduced toxicity, as well as the potential for tumor down-staging and sphincter preservation, neoadjuvant approaches became the preferred method of administering chemotherapy and radiation. Furthermore, a subgroup of patients has been shown to present with complete clinical response to neoadjuvant therapy. This has resulted in the development of the non-operative "watch and wait" approach, which has initiated discussions on changing the interval from the completion of neoadjuvant therapy to surgical resection. The continued development of the multidisciplinary approach will only further improve our ability to provide patients with the best possible oncologic outcomes.
Collapse
|
47
|
Role of intraoperative frozen section for assessing distal resection margin after anterior resection. Int J Colorectal Dis 2015; 30:1081-9. [PMID: 25982468 DOI: 10.1007/s00384-015-2244-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The use of neoadjuvant long-course chemoradiotherapy (LCRT), shorter distal safety margins (DSMs) and stapled or intersphincteric resections has increased sphincter preservation rates. While intraoperative frozen section (IOFS) is not mandatory, it helps achieve negative distal resection margins (DRMs). Our aim was to audit the role of IOFS for DRM assessment while performing sphincter-saving rectal surgery and to identify those subgroups that would benefit the most from IOFS analysis. METHODS Patients who underwent rectal cancer surgery between 2009 and 2013 were identified from a prospectively maintained database. Patients who intraoperatively underwent an IOFS for DRM assessment were included in the study. Factors associated with a positive margin on IOFS were analysed. The sensitivity and specificity of IOFS were also assessed. RESULTS Of 250 patients, who had an anterior resection with an IOFS, 12 had an involved DRM. Of these patients, eight were involved by adenocarcinoma, two by acellular mucin, one by moderate dysplasia and one by adenoma confirmed on paraffin section. Positive margins had a 100 % intervention rate. There were two false negative on IOFS. IOFS had a sensitivity of 85.17 % with a specificity of 100 % and a negative predictive value of 99.16 %. Specimens with a positive IOFS were lower rectal (P < 0.05), poorly differentiated and post LCRT locally advanced tumours. CONCLUSIONS IOFS to confirm negative DRM is recommended in lower rectal tumours irrespective of DSM. It can be considered for locally advanced post LCRT poorly differentiated mid rectal tumours and avoided for upper rectal tumours.
Collapse
|
48
|
Lee SY, Jo JS, Kim HJ, Kim CH, Kim YJ, Kim HR. Prognostic factors for low rectal cancer patients undergoing intersphincteric resection after neoadjuvant chemoradiation. J Surg Oncol 2015; 111:1054-8. [DOI: 10.1002/jso.23932] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 04/18/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Soo Young Lee
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Jeong Seon Jo
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Hun Jin Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Chang Hyun Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Young Jin Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| | - Hyeong Rok Kim
- Department of Surgery; Chonnam National University Hwasun Hospital and Medical School; Hwasun Korea
| |
Collapse
|
49
|
Kulaylat MN. Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance. World J Surg Proced 2015; 5:27-40. [DOI: 10.5412/wjsp.v5.i1.27] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023] Open
Abstract
Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.
Collapse
|
50
|
Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|