Can the Heald anal stent help to reduce anastomotic or rectal stump leak in elective and emergency colorectal surgery? A single-center experience

Anastomotic and rectal stump leaks are feared complications of colorectal surgery. Diverting stomas are commonly used to protect low rectal anastomoses but can have adverse effects. Studies have reported favorable outcomes for transanal drainage devices instead of diverting stomas. We describe our use of the Heald anal stent and its potential impact in reducing anastomotic or rectal stump leak after elective or emergency colorectal surgery. We performed a single-center retrospective analysis of patients in whom a Heald anal stent had been used to "protect" a colorectal anastomosis or a rectal stump, in an elective or emergency context, for benign and malignant pathology. Intraoperative and postoperative outcomes were reviewed using clinical and radiological records. The Heald anal stent was used in 93 patients over 4 years. Forty-six cases (49%) had a colorectal anastomosis, and 47 (51%) had an end stoma with a rectal stump. No anastomotic or rectal stump leaks were recorded. We recommend the Heald anal stent as a simple and affordable adjunct that may decrease anastomotic and rectal stump leak by reducing intraluminal pressure through drainage of fluid and gas.

European consensus on the standardization of robotic total mesorectal excision for rectal cancer

AIM

Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency-based training programme through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons.

METHOD

A Delphi questionnaire with a 72-item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval.

RESULTS

The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75-1).

CONCLUSION

This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.

A personal perspective of the development of MRI for Total Mesorectal Excision surgery

In this personal account Professor Heald discusses the international implementation of total mesorectal excision for rectal cancer and the development of a generation of "specimen-orientated" surgeons. He describes the importance of the surgeon, radiologist and pathologist working together to improve techniques in all three disciplines and the research challenges for the future.

The Perfect Total Mesorectal Excision Obviates the Need for Anything Else in the Management of Most Rectal Cancers

This article discusses the local control of primary rectal cancer and its locoregional spread in the light of modern advances. In recent years, the use of neoadjuvant chemoradiation has spread widely. However, its true benefit is not always balanced with its morbidities. Often total mesorectal excision (TME) is the best option. We will discuss the indications for immediate surgery for chemoradiation in advance and the importance of a delay in the management plan. To understand this selection, it is mandatory to know the true extent of tissue at risk for tumor dissemination and spread. Considering that TME may be enough for many patients and that most local recurrences are failures of surgical technique we introduce a new concept of total mesorectal irradiation. This exploits the new reality that precise, focused neoadjuvant therapy can offer a better response with fewer complications. Together these important changes in cancer board (multidisciplinary team) planning can also offer selected patients complete control of their cancer with no need for surgery.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Adjuvant therapy decisions based on magnetic resonance imaging of extramural venous invasion and other prognostic factors in colorectal cancer

INTRODUCTION

There remains a lack of high quality randomised trial evidence for the use of adjuvant chemotherapy in stage II rectal cancer, particularly in the presence of high risk features such as extramural venous invasion (EMVI). The aim of this study was to explore this issue through a survey of colorectal surgeons and gastrointestinal oncologists.

METHODS

An electronic survey was sent to a group of colorectal surgeons who were members of the Association of Coloproctology of Great Britain and Ireland. The survey was also sent to a group of gastrointestinal oncologists through the Pelican Cancer Foundation. Reminder emails were sent at 4 and 12 weeks.

RESULTS

A total of 142 surgeons (54% response rate) and 99 oncologists (68% response rate) responded to the survey. The majority in both groups of clinicians thought EMVI was an important consideration in adjuvant treatment decision making and commented routinely on this in their multidisciplinary team meeting. Although both would consider treating patients on the basis of EMVI detected by magnetic resonance imaging, oncologists were more selective. Both surgeons and oncologists were prepared to offer patients with EMVI adjuvant chemotherapy but there was lack of consensus on the benefit.

CONCLUSIONS

This survey reinforces the evolution in thinking with regard to adjuvant therapy in stage II disease. Factors such as EMVI should be given due consideration and the prognostic information we offer patients must be more accurate. Historical data may not accurately reflect today's practice and it may be time to consider an appropriately designed trial to address this contentious issue.

A pictorial description of extralevator abdominoperineal excision for low rectal cancer

AIM

Extralevator abdominoperineal excision in the prone position has been reported as a method to improve the poor outcome sometimes observed after abdominoperineal excision (APE) for low rectal cancer. In this paper a pictorial guide is presented describing the key anatomical steps and landmarks of the operation.

METHOD

Intraoperative footage of five APE operations filmed in high definition was reviewed and key stages of the operation were identified. Still frames were captured from these sequences to illustrate this guide. An edited video sequence was produced from one of these operations to accompany this paper.

CONCLUSION

The prone APE allows improved visualization of the perineal portion of the operation by the surgeon, assistants and observers. It permits clear demonstration for teaching. Prospective evaluation is still required to identify patients who would benefit from extralevator APE.

Relevance of magnetic resonance imaging-detected pelvic sidewall lymph node involvement in rectal cancer

BACKGROUND

The significance of magnetic resonance imaging (MRI)-suspected pelvic sidewall (PSW) lymph node involvement in rectal cancer is uncertain.

METHODS

Magnetic resonance images were reviewed retrospectively by specialist gastrointestinal radiologists for the presence of suspicious PSW nodes. Scans and outcome data were from patients with biopsy-proven rectal cancer and a minimum of 5 years' follow-up in the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study. Overall disease-free survival (DFS) was analysed using the Kaplan-Meier product-limit method and stratified according to preoperative therapy. Binary logistic regression was used to match patients for propensity of clinical and staging characteristics, and further survival analysis was carried out to determine associations between suspicious PSW nodes on MRI and survival outcomes.

RESULTS

Of 325 patients, 38 (11·7 per cent) had MRI-identified suspicious PSW nodes on baseline scans. Such nodes were associated with poor outcomes. Five-year DFS was 42 and 70·7 per cent respectively for patients with, and without suspicious PSW nodes (P < 0·001). Among patients undergoing primary surgery, MRI-suspected PSW node involvement was associated with worse 5-year DFS (31 versus 76·3 per cent; P = 0·001), but the presence of suspicious nodes had no impact on survival among patients who received preoperative therapy. After propensity matching for clinical and tumour characteristics, the presence of suspicious PSW nodes on MRI was not an independent prognostic variable.

CONCLUSION

Patients with suspicious PSW nodes on MRI had significantly worse DFS that appeared improved with the use of preoperative therapy. These nodes were associated with adverse features of the primary tumour and were not an independent prognostic factor.

Outcomes following a limited approach to radiotherapy in rectal cancer

BACKGROUND

Variation in the use of neoadjuvant and adjuvant radiotherapy for rectal cancer suggests an opportunity to avoid it in all but patients at highest risk of local recurrence.

METHODS

Between 1 July 1999 and 1 February 2006, patients with primary rectal cancer were treated by a single surgeon operating at McMaster University, Hamilton, Ontario, Canada. Digital rectal examination and pelvic computed tomography were used to determine whether the mesorectal margin was threatened by tumour and thus whether preoperative radiotherapy would be needed. The study outcome was local tumour recurrence.

RESULTS

Forty-six (48 per cent) of 96 patients received preoperative radiation therapy. The median follow-up was 4·2 years. Tumours were fixed or tethered in 31 (67 per cent) of the 46 irradiated patients. In contrast, no tumour was fixed in unirradiated patients and only ten (20 per cent) of the 50 tumours were tethered. The proportion of patients with stage I or II tumours based on final pathology was similar: 61 per cent (28 of 46) and 56 per cent (28 of 50) in irradiated and unirradiated groups respectively (P = 0·287). There were four (9 per cent) and two (4 per cent) local recurrences among irradiated and unirradiated patients respectively (P = 0·422).

CONCLUSION

Limiting preoperative radiotherapy in rectal cancer to patients with a threatened circumferential margin does not compromise patient outcome.

One millimetre is the safe cut-off for magnetic resonance imaging prediction of surgical margin status in rectal cancer

BACKGROUND

A pathologically involved margin in rectal cancer is defined as tumour within 1 mm of the surgical resection margin. There is no standard definition of a predicted safe margin on magnetic resonance imaging (MRI). The aim of this study was to assess which cut-off (1, 2 or 5 mm) was the best predictor of local recurrence based on preoperative MRI assessment of the circumferential resection margin (CRM).

METHODS

Data were collected prospectively on the distance between the tumour and mesorectal fascia for patients with documented radiological margin status in the MERCURY study. Positive margin and local recurrence rates were compared for MRI distances from the tumour to the mesorectal fascia of 1 mm or less, more than 1 mm up to 2 mm, more than 2 mm up to 5 mm, and more than 5 mm. The Cox proportional hazard regression method was used to determine the effect of level of margin involvement on time to local recurrence.

RESULTS

Univariable analysis showed that, relative to a distance measured by MRI of more than 5 mm, the hazard ratio (HR) for local recurrence was 3·90 (95 per cent confidence interval 1·99 to 7·63; P < 0·001) for a margin of 1 mm or less, 0·81 (0·36 to 1·85; P = 0·620) for a margin of more than 1 mm up to 2 mm, and 0·33 (0·10 to 1·08; P = 0·067) for a margin greater than 2 mm up to 5 mm. Multivariable analysis of the effect of MRI distance to the mesorectal fascia and preoperative treatment on local recurrence showed that a margin of 1 mm or less remained significant regardless of preoperative treatment (HR 3·72, 1·43 to 9·71; P = 0·007).

CONCLUSION

For preoperative staging of rectal cancer, the best cut-off distance for predicting CRM involvement using MRI is 1 mm. Using a cut-off greater than this does not appear to identify patients at higher risk of local recurrence.

Magnetic resonance imaging-detected lymph nodes close to the mesorectal fascia are rarely a cause of margin involvement after total mesorectal excision

BACKGROUND

In rectal cancer the management of suspicious magnetic resonance imaging (MRI)-detected lymph nodes lying close to the mesorectal fascia poses an ongoing dilemma. Key decisions in treatment planning are commonly based on the prediction of margin status. However, it is unclear whether a lymph node that appears to contain tumour close to the mesorectal fascia will result in a positive margin.

METHODS

Some 396 patients with rectal cancer were included. MRI assessment of mesorectal nodes, the pathologically involved circumferential resection margin (CRM) rate and causes of margin involvement were analysed to establish the clinical significance of MRI-detected suspicious lymph nodes at the resection margin.

RESULTS

Fifty (12.6 per cent) of 396 patients had a positive CRM on histopathological analysis, five (10 per cent) solely due to an involved lymph node. Four of the five malignant nodes were not predicted on MRI. Thirty-one of the 396 MRI studies had suspicious nodes 1 mm or less from the CRM. None of these patients had a positive CRM owing to nodal involvement.

CONCLUSION

Involvement of the CRM by lymph node metastases alone is uncommon.

Rectal cancer surgery and regional lymph nodes

In patients with rectal cancer, the status of regional or mesorectal lymph nodes is central to both tumor staging and predicting local and distant recurrence. The importance of mesorectal lymph nodes in rectal cancer should inform treatment decisions around pre-operative diagnostic imaging, surgical techniques, pathologic assessment, and the use of radiation therapy.

Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer

BACKGROUND

The objective of this study was to assess the value of preoperative pelvimetry, using magnetic resonance imaging (MRI), in predicting the risk of an involved circumferential resection margin (CRM) in a group of patients with operable rectal cancer.

METHODS

A cohort of 186 patients from the MERCURY study was selected. These patients' histological CRM status was compared against 14 pelvimetry parameters measured from the preoperative MRI. These measurements were taken by one of the investigators (G.S.), who was blinded to the final CRM status.

RESULTS

There was no correlation between the pelvimetry and the CRM status. However, there was a difference in the height of the rectal cancer and the positive CRM rate (p = 0.011). Of 61 patients with low rectal cancer, 10 had positive CRM at histology (16.4% with CI 8.2%-22.1%) compared with 5 of 110 patients with mid/upper rectal cancers (4.5% with CI 0.7%-8.4%).

CONCLUSIONS

Magnetic resonance imaging can predict clear margins in most cases of rectal cancer. Circumferential resection margin positivity cannot be predicted from pelvimetry in patients with rectal cancer selected for curative surgery. The only predictive factor for a positive CRM in the patients studied was tumor height.

Non-operative treatment after neoadjuvant chemoradiotherapy for rectal cancer

The past decade has seen pronounced changes in the treatment of locally advanced rectal cancer. Historically, the standard of care involved surgery followed by adjuvant radiotherapy or chemoradiotherapy. More recently, the emergence of neo-adjuvant chemoradiotherapy has fundamentally changed the management of patients with locally advanced disease. In clinical trials, pathological complete responses of up to 25% have raised the question as to whether surgery can be avoided in a select cohort of patients. A trial of omission of surgery for selected patients with complete response after preoperative chemoradiotherapy has shown favourable long-term results. In this article, we outline emerging factors for achieving pathological complete response, non-operative strategies to date, methods for prediction of response to chemoradiotherapy, and future directions with the addition of MRI as a radiological guide to complete response.

Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence

OBJECTIVE

The current optimal management of locally advanced rectal cancer has evolved from surgical excision followed by postoperative therapy in patients with involved margins, to an increasing use of a preoperative strategy to 'down-stage and/or down-size' the tumour. This treatment strategy is based on the relationship of the tumour to the mesorectal fascia, the optimal surgical circumferential resection margin that can be achieved by total mesorectal excision. We have reviewed the recent evidence for this strategy.

METHOD

An electronic literature search using PubMed identified articles on the subject of rectal cancer between January 2000 and December 2005. The search was limited to English language publications with secondary references obtained from key articles. Articles published in high impact factor journals formed the basis of the review, together with articles related to national programmes on the management of rectal cancer. This does lead to a selection bias, particularly as the articles identified had a European bias.

CONCLUSION

The UK NHS Cancer Plan has outlined the basis for the multidisciplinary team (MDT) management of rectal cancer. Advances in preoperative assessment through accurate staging and the recognition of the importance of the relationship of the tumour to the mesorectal fascia has allowed the selection of patients for a preoperative strategy to down-size/down-stage the tumour if this fascial layer is involved or threatened. Improvements in the quality of surgical resection through the acceptance of the principle of total mesorectal excision have ensured that optimal surgery remains the cornerstone to successful treatment. Further refinements of the MDT process strive to improve outcome. Accurate radiological staging, optimal surgery and detailed histopathological assessment together with consideration of a preoperative neoadjuvant strategy should now form the basis for current treatment and future research in rectal cancer.

Long-term results show triple stapling facilitates safe low colorectal and coloanal anastomosis and is associated with low rates of local recurrence after anterior resection for rectal cancer

BACKGROUND

During low anterior resection (AR), placement of a staple line distal to an occlusion clamp is often difficult due to the confines of a narrow bony pelvis. This study reviewed the results of AR with a technique in which a linear staple line is fired below the tumour as an oncologically safe occlusion clamp.

METHODS

Between 1995 and 2000, a total of 174 patients were operated for rectal cancer, and 153 of these patients had AR. Triple stapling (TS) was used to place a line of staples that occluded the fully mobilised rectum below a tumour. After rectal washout, a further linear stapler was applied below the first, and the rectum was divided prior to a standard circular stapled anastomosis.

RESULTS

TS was performed in 127 (83%) of 153 patients undergoing AR, and 9 TS patients developed leaks (7%). In the whole series of 174 cases, 9 patients had local recurrence (5%), but the local recurrence rate for procedures classified as 'locally curative' was 2%.

CONCLUSIONS

Triple stapling reliably occludes the rectum allowing for distal rectal washout. It eliminates clamp slippage and faecal spillage and improves access to the distal rectum for low anastomoses.

Magnetic resonance imaging pelvimetry in 186 patients with rectal cancer confirms an overlap in pelvic size between males and females

INTRODUCTION

It has generally been considered that open pelvic surgery is almost always easier in female subjects because of anatomical differences facilitating surgical access. In contrast, the male pelvis has been considered to be narrower and deeper. The objective of this study was to assess magnetic resonance imaging (MRI) pelvimetry in patients with rectal cancer in whom any difference in pelvimetry may potentially affect operative management. Male and female pelvic bony dimensions were compared.

METHOD

A cohort of 186 patients (112 males and 74 females) with rectal cancer who had been recruited prospectively to the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study (MERCURY Study) were assessed. Complete digital images were available on these patients. A comparison of the pelvic dimensions was made between the sexes using 16 dimensions measured on the MRI workstation using the mid-sagittal and axial images.

RESULTS

There was no significant difference and considerable overlap between the sexes with respect to each of the 14 parameters measured from the preoperative sagittal MRI scan. However, there was a highly significant difference between the interspinous and intertuberous transverse diameter of the pelvis (P < 0.0001).

CONCLUSION

Outcome after surgery may be influenced by the technical difficulty of the operation and this had been thought to be partly affected by the pelvic size. In this cohort of 186 patients, the only difference seen between the sexes, was in the transverse mid-inlet and pelvic outlet diameter.

The Pelican Cancer Foundation and The English National MDT-TME Development Programme

The formation of The Pelican Cancer Foundation in 2000 was based around the pioneering work of Professor Bill Heald and colleagues, and the development of Total Mesorectal Excision (TME) for rectal cancer. A series of surgical workshops in Scandinavia in the mid 1990s and, later, six further workshops in the Trent region culminated in the commissioning of the fully multidisciplinary National MDT-TME Development Programme by the National Cancer Director, Professor Mike Richards, in March 2003.

Defining the rectum: surgically, radiologically and anatomically

The terminology used in relation to the rectum varies considerably, added to this there is the subjective nature of clinical assessment and variability in the anatomy of the rectum and anus. It is imperative that definitions are clarified and standardized for use by all members of the multidisciplinary team involved in the care of patients with rectal cancer.

Almost all five year disease free survivors are cured following rectal cancer surgery, but longer term follow-up detects some late local and systemic recurrences

BACKGROUND

The necessity, timing and benefits of follow-up after rectal cancer surgery remain controversial, with two years traditionally considered adequate to detect most local recurrences. This unit has a policy of lifetime follow-up, and this paper investigates, at 23 years, the value of prolonged surveillance.

METHOD

Six hundred and sixty consecutive patients undergoing surgery for rectal cancer were prospectively followed-up between 1978 and 2002, and local or systemic recurrence recorded. This analysis was performed on the 509/660 (76%) patients who underwent potentially curative surgery.

RESULTS

Total mesorectal excision (TME) was performed in 422/509 (83%) patients, mesorectal transection in 78 (15%), and local excision in 9 (2%). Follow-up ranged from 1 to 23 years (mean = 9.7). Seven (1.4%) patients had local recurrence alone, 11 (2.2%) local plus systemic, and 86 (17%) systemic recurrence alone. Of the local recurrences 3 (17%) became evident within 1 year, 9 (50%) within 2 years, 16 (89%) within 5 years, and 2 (11%) presented after 5 years, at 5.6 and 5.8 years. Of the systemic recurrences 26 (27%) became evident within 1 year, 57 (59%) within 2 years, 93 (96%) within 5 years, and 4 (4%) presented after 5 years at 5.3, 5.3, 5.4 and 7.9 years.

CONCLUSION

This long-term surveillance of patients undergoing curative surgery for rectal cancer demonstrates that most local and systemic recurrences occur within 5 years. Almost half occurred more than 2 years after surgery. However, those centres wishing to set standards of care, or evaluate current or new therapies in rectal cancer treatment, should be aware that unexpected late recurrences occasionally develop.

Impact of a surgical training programme on rectal cancer outcomes in Stockholm

BACKGROUND

Total mesorectal excision (TME) and use of adjuvant radiotherapy are major advances in the treatment of rectal cancer that have emerged in the past 20 years. The aim of this study was to evaluate the effects of an initiative to teach the TME technique on outcomes at 5 years after surgery.

METHODS

TME-based surgery was introduced in Stockholm in 1994. The study population comprised all 447 patients who underwent abdominal operations for rectal cancer in Stockholm County during 1995 and 1996. Outcomes were compared with those in the Stockholm I (790 patients) and Stockholm II (542 patients) radiotherapy trials.

RESULTS

The permanent stoma rate was reduced from 60.3 and 55.3 per cent in the Stockholm I and II trials respectively to 26.5 per cent in the TME project (P < 0.001). Five-year local recurrence rates decreased from 21.9 and 19.1 per cent to 8.2 per cent respectively (P < 0.001). Five-year cancer-specific survival rates increased from 66.0 and 65.7 per cent in the Stockholm trials to 77.3 per cent in the TME project (hazard ratio 0.62 (95 per cent confidence interval 0.49 to 0.80); P < 0.001).

CONCLUSION

A surgical teaching programme had a major impact on rectal cancer outcome.

Irreversible lower limb ischaemia following ligation of the inferior mesenteric artery in the surgical treatment of rectal cancer

Rectal cancer and cardiovascular disease are both commoner in the elderly and may coexist. In some severe arteriopaths the blood supply to the lower limbs may be a collateral circulation from the inferior mesenteric artery. Patients with aorto-iliac occlusion or severe stenosis may have collaterals from the inferior mesenteric artery to the lower limb blood vessels. Ligation of the inferior mesenteric artery in treating rectal cancer can result in irreversible ischaemia as outlined in this report. Routine palpation of the femoral pulses and awareness of collateral circulation may avoid the disastrous consequences seen in the two cases described.