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Sun S, Sun S, Zheng X, Yu J, Wang W, Gong Q, Zhao G, Li J, Zhang H. Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment. BMC Cancer 2022; 22:916. [PMID: 36002810 PMCID: PMC9404665 DOI: 10.1186/s12885-022-10019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Extralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes. Methods Medical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed. Results The mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%. Conclusions Laparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10019-2.
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Affiliation(s)
- Shaowei Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Shengbo Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Xiangyun Zheng
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jiangtao Yu
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Wenchang Wang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Qing Gong
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Guowei Zhao
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jing Li
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China.
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Nie K, Hu P, Zheng J, Zhang Y, Yang P, Jabbour SK, Yue N, Dong X, Xu S, Shen B, Niu T, Hu X, Cai X, Sun J. Incremental Value of Radiomics in 5-Year Overall Survival Prediction for Stage II-III Rectal Cancer. Front Oncol 2022; 12:779030. [PMID: 35847948 PMCID: PMC9279662 DOI: 10.3389/fonc.2022.779030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Although rectal cancer comprises up to one-third of colorectal cancer cases and several prognosis nomograms have been established for colon cancer, statistical tools for predicting long-term survival in rectal cancer are lacking. In addition, previous prognostic studies did not include much imaging findings, qualitatively or quantitatively. Therefore, we include multiparametric MRI information from both radiologists' readings and quantitative radiomics signatures to construct a prognostic model that allows 5-year overall survival (OS) prediction for advance-staged rectal cancer patients. The result suggested that the model combined with quantitative imaging findings might outperform that of conventional TNM staging or other clinical prognostic factors. It was noteworthy that the identified radiomics signature consisted of three from dynamic contrast-enhanced (DCE)-MRI, four from anatomical MRI, and one from functional diffusion-weighted imaging (DWI). This highlighted the importance of multiparametric MRI to address the issue of long-term survival estimation in rectal cancer. Additionally, the constructed radiomics signature demonstrated value to the conventional prognostic factors in predicting 5-year OS for stage II-III rectal cancer. The presented nomogram also provides a practical example of individualized prognosis estimation and may potentially impact treatment strategies.
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Affiliation(s)
- Ke Nie
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Peng Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Zheng
- Department of Radiology, Hwa Mei Hospital, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, University of Chinese Academy of Sciences, Ningbo, China
| | - Yang Zhang
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Pengfei Yang
- Institute of Translational Medicine, Zhejiang University, Hangzhou, China
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Ning Yue
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Xue Dong
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shufeng Xu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Shen
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tianye Niu
- Institute of Translational Medicine, Zhejiang University, Hangzhou, China
| | - Xiaotong Hu
- Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujun Cai
- Department of General Surgery, Innovation Center for Minimally Invasive Techniques and Devices, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jihong Sun
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Innovation Center for Minimally Invasive Techniques and Devices, Zhejiang University, Hangzhou, China
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Zhang H, Li G, Cao K, Zhai Z, Wei G, Ye C, Zhao B, Wang Z, Han J. Long-term outcomes after extra-levator versus conventional abdominoperineal excision for low rectal cancer. BMC Surg 2022; 22:242. [PMID: 35733206 PMCID: PMC9219120 DOI: 10.1186/s12893-022-01692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Extralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is achieved in patients undergoing ELAPE, the long-term benefits have not been established. In this study we evaluated the safety, pathological and survival outcomes in rectal cancer patients who underwent ELAPE and APE. METHODS One hundred fourteen patients were enrolled, including 68 in the ELAPE group and 46 in the APE group at the Beijing Chaoyang Hospital, Capital Medical University from January 2011 to November 2020. The baseline characteristics, overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS) were calculated and compared between the two groups. RESULTS Demographics and tumor stage were comparable between the two groups. The 5-year PFS (67.2% versus 38.6%, log-rank P = 0.008) were significantly improved in the ELAPE group compared to the APE group, and the survival advantage was especially reflected in patients with pT3 tumors, positive lymph nodes or even those who have not received neoadjuvant chemoradiotherapy. Multivariate analysis showed that APE was an independent risk factor for OS (hazard ratio 3.000, 95% confidence interval 1.171 to 4.970, P = 0.004) and PFS (hazard ratio 2.730, 95% confidence interval 1.506 to 4.984, P = 0.001). CONCLUSION Compared with APE, ELAPE improved long-term outcomes for low rectal cancer patients, especially among patients with pT3 tumors, positive lymph nodes or those without neoadjuvant chemoradiotherapy.
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Affiliation(s)
- Haoyu Zhang
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Ganbin Li
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Ke Cao
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Zhiwei Zhai
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Guanghui Wei
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Chunxiang Ye
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Baocheng Zhao
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Zhenjun Wang
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China.
| | - Jiagang Han
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China.
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Wilkins S, Yap R, Mendis S, Carne P, McMurrick PJ. Surgical Techniques for Abdominoperineal Resection for Rectal Cancer: One Size Does Not Fit All. Front Surg 2022; 9:818097. [PMID: 35284486 PMCID: PMC8907259 DOI: 10.3389/fsurg.2022.818097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Abdominoperineal resection (APR) of rectal cancer is associated with poorer oncological outcomes than anterior resection. This may be due to higher rates of intra-operative perforation (IOP) and circumferential resection margin (CRM) involvement causing higher recurrence rates and surgical complications. To address these concerns, several centers advocated a change in technique from a standard APR to a more radical extra-levator abdominoperineal excision (ELAPE). Initial reports showed that ELAPE reduced IOP rates and CRM involvement but increased wound complications and longer surgical duration. However, many of these studies had unacceptable rates of IOP and CRM before retraining in ELAPE. This may indicate that it was a sub-optimal surgical technique, which improved upon training, that had influenced the high CRM and IOP rates rather than the technique itself. Subsequent studies demonstrated that the CRM involvement rate for ELAPE was not always lower than for standard APR and, in some cases, significantly higher. The morbidity of ELAPE can be high, with studies reporting higher adverse events than APR, especially in terms of wound complications from the larger perineal incision required in ELAPE. Whether ELAPE improves short- or long-term oncological outcomes for patients has not been clearly demonstrated. The authors propose that all centers performing rectal cancer surgery audit surgical outcomes of patients undergoing APR or ELAPE and examine CRM involvement, IOP rates, and local recurrence rates, preferably through a national body. If rates of adverse technical or oncological outcomes exceed acceptable levels, then retraining in the appropriate surgical techniques may be indicated.
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Affiliation(s)
- Simon Wilkins
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- *Correspondence: Simon Wilkins
| | - Raymond Yap
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - Shehara Mendis
- Department of Oncology Research, Cabrini Hospital, Malvern, VIC, Australia
| | - Peter Carne
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Colorectal Unit, Department of Surgery, Alfred Hospital, Melbourne, VIC, Australia
| | - Paul J. McMurrick
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
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Valadão M, Cesar D, Véo CAR, Araújo RO, do Espirito Santo GF, Oliveira de Souza R, Aguiar S, Ribeiro R, de Castro Ribeiro HS, de Souza Fernandes PH, Oliveira AF. Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer. J Surg Oncol 2021; 125:194-216. [PMID: 34585390 DOI: 10.1002/jso.26676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.
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Affiliation(s)
- Marcus Valadão
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Daniel Cesar
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | - Rodrigo Otávio Araújo
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Reitan Ribeiro
- Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
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Sato K, Shimoda H, Miura T, Sakamoto Y, Morohashi H, Watanabe S, Narita H, Mitsuhashi Y, Umemura K, Hakamada K. Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging. Colorectal Dis 2021; 23:1334-1345. [PMID: 33570769 PMCID: PMC8248146 DOI: 10.1111/codi.15582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 01/11/2023]
Abstract
AIM Abdominoperineal resection is associated with poor prognosis in patients with advanced lower rectal cancer. This study aimed to analyse the functional lymphovascular network and tissue drainage in the anorectal region. METHODS In this descriptive study, we performed microanatomical evaluations and intra-operative imaging analysis in a cadaver and patients with rectal cancer. Specimens with India ink injection were collected from a cadaver and from six patients who underwent abdominoperineal resection. Intra-operative indocyanine green fluorescence imaging was performed on four patients who underwent surgery for lower rectal cancer. India ink was injected into the submucosa at the dentate line of specimens. Tissue sections were examined by immunohistochemistry for D2-40 and CD31. Intra-operative indocyanine green was injected into the submucosa at the dentate line. Lymph flow was traced using a near-infrared camera system. RESULTS Fascia branching from the rectal longitudinal muscle layer extended to the posterior hiatal ligament and lateral endopelvic fascia connective tissue lamina on the surface of the levator ani muscle. The fascia contained veins labelled with ink in their lumina and initial lymphatics. Intra-operative indocyanine green fluorescence imaging revealed extensive lymph flow from the muscle layer of the anal canal to the hiatal ligament and endopelvic fascia along the longitudinal muscle layer fibres. CONCLUSIONS The anorectal region contained widespread venous and lymphatic networks in proportion to its specific connective tissue framework around the longitudinal-muscle-layer-extending muscle bundles, which provides extensive networks for tissue fluid and cells.
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Affiliation(s)
- Kentaro Sato
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Hiroshi Shimoda
- Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Neuroanatomy, Cell Biology, HistologyGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Takuya Miura
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Hajime Morohashi
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Seiji Watanabe
- Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Hirokazu Narita
- Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Yuto Mitsuhashi
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Kotaro Umemura
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
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Cylindrical abdominoperineal resection rationale, technique and controversies. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AbstractSurgery remains the cornerstone in rectal cancer treatment. Abdominoperineal excision (APE), described more than 100 years ago, remains as an important procedure for the treatment of selected advanced distal tumors with direct invasion of the anal sphincter or preoperative fecal incontinence. Historically, oncological outcomes of patients undergoing APE have been worse when compared to sphincter preserving operations. More recently, it has been suggested that patients undergoing APE for distal rectal cancer are more likely to have positive circumferential resection margins and intraoperative perforation, known surrogate markers for local recurrence. Recently, an alternative approach known as “Extralevator Abdominoperineal Excision” has been described in an effort to improve rates of circumferential margin positivity possibly resulting in better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard abdominal perineal excision techniques.
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Jouppe PO, Courtot L, Sindayigaya R, Moussata D, Barbieux JP, Ouaissi M. Trans-anal total mesorectal excision in low rectal cancers: Preliminary oncological results of a comparative study. J Visc Surg 2020; 159:13-20. [PMID: 33358754 DOI: 10.1016/j.jviscsurg.2020.12.001] [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: 10/22/2022]
Abstract
OBJECTIVE The management of lower rectal cancers is a therapeutic challenge both from the oncological and functional viewpoints. The aim of this study is to assess the oncological results and postoperative morbidity after transanal total mesorectal excision (TaTME) for low rectal cancer. MATERIAL AND METHODS In this monocentric retrospective study, we compared the quality of carcinologic resection and the morbidity-mortality between a group of 20 patients undergoing TaTME and 21 patients treated by abdomino-perineal resection (APR) between 2016 to 2019. RESULTS More patients had a positive circumferential resection margin (CRM) (≤1mm) in the APR group (47.6% vs. 5%; P<0.0036). The difference in the rates of grades I-II and III-IV complications (Clavien-Dindo classification) between the two groups was not statistically significant (50% vs. 57.1% and 5% vs. 9.5% in TaTME and APR, respectively; P=0.7579, P=1.00). The median follow-up was longer in the TaTME group (20 months vs. 11 months; P=0.58). The local recurrence rate did not differ between the two groups (5% vs. 4.8%; P=1.00) CONCLUSION: TaTME provides a reliable total mesorectal resection with an acceptable CRM. However, like any new technique, it requires experience and the learning curve is long.
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Affiliation(s)
- P-O Jouppe
- Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplantation Surgery, Trousseau Hospital, CHU de Tours, avenue de la République, Chambray-les-Tours, France
| | - L Courtot
- Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplantation Surgery, Trousseau Hospital, CHU de Tours, avenue de la République, Chambray-les-Tours, France
| | - R Sindayigaya
- Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplantation Surgery, Trousseau Hospital, CHU de Tours, avenue de la République, Chambray-les-Tours, France
| | - D Moussata
- Gastroenterology Department, Trousseau Hospital, CHU de Tours, Tours, France
| | - J-P Barbieux
- Gastroenterology Department, Trousseau Hospital, CHU de Tours, Tours, France
| | - M Ouaissi
- Department of Digestive, Oncological, Endocrine, Hepatobiliary and Liver Transplantation Surgery, Trousseau Hospital, CHU de Tours, avenue de la République, Chambray-les-Tours, France.
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Improved Outcomes for Rectal Cancer in the Era of Preoperative Chemoradiation and Tailored Mesorectal Excision: A Series of 338 Consecutive Cases. Am Surg 2020. [DOI: 10.1177/000313481307900225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N1 disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.
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Nahas S, Nahas C, Bustamante-Lopez L, Pinto R, Marques C, Cecconello I. Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Nahas SC, Nahas CSR, Bustamante-Lopez LA, Pinto RA, Marques CFS, Cecconello I. Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:180-189. [PMID: 32057523 DOI: 10.1016/j.rgmx.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/19/2019] [Accepted: 05/30/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND AIM Surgery for distal rectal cancer (DRC) can be performed with or without sphincter preservation. The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients: low anterior resection (LAR) and abdominoperineal resection (APR). METHODS Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated. We compared the outcomes of the type of surgery (APR vs LAR) and analyzed the associations of survival and recurrence with the following factors: age, sex, tumor location, lymph nodes obtained, lymph node involvement, and rectal wall involvement. Patients with distant metastases were excluded. RESULTS A total of 148 patients were included, 78 of whom were females (52.7%). The mean patient age was 61.2years. Neoadjuvant chemoradiation therapy was performed in 86.5% of the patients. APR was performed on 86 (58.1%) patients, and LAR on 62 (41.9%) patients. No differences were observed between the two groups regarding clinical and oncologic characteristics. Eighty-seven (62%) patients had pT3-4 disease, and 41 patients (27.7%) had lymph node involvement. In the multivariate analysis, only poorly differentiated tumors (P=.026) and APR (P=.009) correlated with higher recurrence rates. Mean follow-up time was 32 (16-59.9) months. Overall 5-year survival was 58.1%. The 5-year survival rate was worse in patients that underwent APR (46.5%) than in the patients that underwent LAR (74.2%) (P=.009). CONCLUSIONS Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR. In addition, advanced T/stage, lymph node involvement, and poor tumor differentiation were associated with recurrence and a lower survival rate, regardless of the procedure.
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Affiliation(s)
- S C Nahas
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - C S R Nahas
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - L A Bustamante-Lopez
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil.
| | - R A Pinto
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - C F S Marques
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
| | - I Cecconello
- División de Cirugía Digestiva del Hospital de Clínicas, Departamento de Gastroenterología de la Escuela de Medicina de la Universidad de Sao Paulo, Sao Paulo, Brasil
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12
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Banwell VC, Phillips HA, Duff MJ, Speake D, McLean C, Williams LJ, He Y, Paterson HM. Five-year oncological outcomes after selective neoadjuvant radiotherapy for resectable rectal cancer. Acta Oncol 2019; 58:1267-1272. [PMID: 31237192 DOI: 10.1080/0284186x.2019.1631473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: There is considerable variation in selection of patients for and type of neoadjuvant radiotherapy administered in the treatment of resectable rectal cancer. The aim of this study was to report outcomes for patients with resected rectal cancer from a unit with step-wise selection for surgery alone, short course radiotherapy (SCRT) or downstaging long course chemoradiotherapy (LCCRT). Material and methods: Cohort analysis of patients with rectal adenocarcinoma resected with curative intent between 2008 and 2012 at a specialist regional colorectal surgery center. The primary endpoints were local recurrence, metastatic recurrence, disease-free survival and overall survival. Exploratory uni- and multi-variable regression analyses were performed to identify predictive factors. Results: About 240 patients were treated by surgery alone, 90 patients received SCRT and 91 patients received LCCRT. Five-year local recurrence was 10.8% in the surgery alone group, 3.3% with SCRT and 18.7% with LCCRT. Metachronous distant metastasis was highest in the SCRT group (13.8% surgery alone, 25.6% SCRT, 15.4% LCCRT). Uni- and multi-variable regression analysis found that local and distant recurrence was attributable predominantly to adverse tumor biology. Conclusions: Patients selected for SCRT had a lower rate of local recurrence than patients selected for surgery alone, but were more likely to develop distant metastasis. There was no difference in overall survival. With low local recurrence rates, distant metastasis is the predominant risk for patients with resectable rectal cancer.
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Affiliation(s)
- Victoria C. Banwell
- On behalf of the Lothian Colorectal Cancer MDM, Western General Hospital, Edinburgh, UK
| | - Hamish A. Phillips
- On behalf of the Lothian Colorectal Cancer MDM, Western General Hospital, Edinburgh, UK
| | - Michael J. Duff
- On behalf of the Lothian Colorectal Cancer MDM, Western General Hospital, Edinburgh, UK
| | - Doug Speake
- On behalf of the Lothian Colorectal Cancer MDM, Western General Hospital, Edinburgh, UK
| | - Catriona McLean
- On behalf of the Lothian Colorectal Cancer MDM, Western General Hospital, Edinburgh, UK
| | - Linda J. Williams
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, Teviot Place, Edinburgh, UK
| | - Yazhou He
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, Teviot Place, Edinburgh, UK
| | - Hugh M. Paterson
- On behalf of the Lothian Colorectal Cancer MDM, Western General Hospital, Edinburgh, UK
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13
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Shen Z, Bu Z, Li A, Lu J, Zhu L, Chong CS, Gao Z, Jiang K, Wang S, Li F, Xiao Y, Ji J, Ye Y. Multicenter study of surgical and oncologic outcomes of extra-levator versus conventional abdominoperineal excision for lower rectal cancer. Eur J Surg Oncol 2019; 46:115-122. [PMID: 31471089 DOI: 10.1016/j.ejso.2019.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/21/2019] [Accepted: 08/20/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The surgical and oncological outcome of extra-levator abdominoperineal excision (ELAPE) procedure remains unclear in low rectal cancer. METHODS A total of 194 cases of rectal cancer patients underwent ELAPE or conventional abdominoperineal excision (APE) procedure were analyzed in four hospitals' databases from January 2010 to December 2015. Clinicopathological data, overall survival (OS), disease free survival (DFS) and local recurrence free survival (LRFS) of patients were compared between two groups. RESULTS The operation time spent in perineal phase was significantly shorter in the ELAPE group than that in conventional APE procedure (P < 0.001). There were more specimens with excellent or good quality in ELAPE group compared to conventional APE group (P = 0.033). Patients whom underwent ELAPE procedures showed significantly better OS, DFS and LRFS than those underwent conventional APE procedures. Patients with preoperative stage cT3∼T4 (P = 0.033, P = 0.008, P = 0,033), cN+ (P = 0.002, P < 0.001, P = 0.006) and pathological stage III-IV (P = 0.023, P = 0.008, P = 0.016) were associated with significant benefits from ELAPE procedure in terms of OS, DFS and LRFS. DFS differed significantly between two groups of patients whom got preoperative chemoradiation therapy (P = 0.009) or postoperative chemotherapy (P = 0.029). For patients of pathological stage IIII-IV without preoperative chemoradiation, ELAPE procedures resulted in statistically better OS (P = 0.018) and DFS (P = 0.030). ELAPE procedure was an independent risk factor of OS, DFS and LRFS in multivariate analysis. CONCLUSION Low rectal cancer patients might benefit from ELAPE procedure on both surgical and oncological outcomes, especially in patients with relatively advanced tumors, inspite of the effects of pre-operative radio- and chemotherapy.
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Affiliation(s)
- Zhanlong Shen
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China.
| | - Zhaode Bu
- Center of Gastrointestinal Surgery, Beijing Cancer Hospital, Beijing, 100142, PR China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, 100053, PR China
| | - Junyang Lu
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, PR China
| | - Liyu Zhu
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China
| | - Choon Seng Chong
- Department of Colorectal Surgery, National University Hospital of Singapore, Singapore
| | - Zhidong Gao
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China
| | - Kewei Jiang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China
| | - Shan Wang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, 100053, PR China.
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, PR China.
| | - Jiafu Ji
- Center of Gastrointestinal Surgery, Beijing Cancer Hospital, Beijing, 100142, PR China.
| | - Yingjiang Ye
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China.
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14
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Lin C, Cai ZC, Tu XH. The comparison between conventional method and perineal-approach-first abdominoperineal resection. Asian J Surg 2019; 42:894-896. [PMID: 31255464 DOI: 10.1016/j.asjsur.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 05/20/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Chen Lin
- Department of General Surgery, Dongfang Hospital, 900 Hospital of the Joint Logistics Team, Fuzhou, Fujian 350025, China.
| | - Zhi-Cong Cai
- Department of Gastroenterological Surgery, Jinjiang Municipal Hospital, Quanzhou, Fujian 352200, China.
| | - Xiao-Huang Tu
- Department of General Surgery, Dongfang Hospital, 900 Hospital of the Joint Logistics Team, Fuzhou, Fujian 350025, China.
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15
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Oncologic outcomes for low rectal adenocarcinoma following low anterior resection with coloanal anastomosis versus abdominoperineal resection: a National Cancer Database propensity matched analysis. Int J Colorectal Dis 2019; 34:843-848. [PMID: 30790033 DOI: 10.1007/s00384-019-03267-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Low anterior resection with coloanal anastomosis (CAA) for low rectal cancer is a technically difficult operation with limited data available on oncologic outcomes. We aim to investigate overall survival and operative oncologic outcomes in patients who underwent CAA compared to abdominoperineal resection (APR). METHODS The National Cancer Database (2004-2013) was used to identify patients with non-metastatic rectal adenocarcinoma who underwent CAA or APR. Patients were 1:1 matched on age, gender, Charlson score, tumor size, tumor grade, pathologic stage, and radiation treatment with propensity scores. The primary outcome was overall survival. Secondary outcomes included 30-day mortality and resection margins. RESULTS Following matching, 3536 patients remained in each group. No significant differences in matched demographic, treatment, or tumor variables were seen between groups. There was no significant difference in 30-day mortality (1.24% vs. 1.39%, p = 0.60). Following resection, margins were more likely to be negative after CAA compared with APR (5.26% vs. 8.14%, p < 0.001). When stratified by pathologic stage, there was a significant survival advantage for individuals undergoing CAA compared to APR (stage 1 HR 0.72, [95% CI 0.62-0.85], p < 0.001; stage 2 HR 0.76, [95% CI 0.65-0.88], p < 0.001; stage 3 HR 0.76, [95% CI 0.67-0.85], p < 0.001). CONCLUSIONS Patients undergoing CAA compared with APR for rectal cancer have better overall survival and are less likely to have positive margins despite the technically challenging operation.
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16
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Wilkins S, Yap R, Loon K, Staples M, Oliva K, Ruggiero B, McMurrick P, Carne P. Surgical outcome after standard abdominoperineal resection: A 15-year cohort study from a single cancer centre. Ann Med Surg (Lond) 2018; 36:83-89. [PMID: 30425830 PMCID: PMC6224354 DOI: 10.1016/j.amsu.2018.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Abdominoperineal resection (APR) is associated with a poorer oncological outcome than anterior resection. This may be due to higher rates of intra-operative perforation and circumferential resection margin involvement. The aim of this study was to audit our short and long-term results of abdominoperineal resection performed using conventional techniques and to compare this with other published series. MATERIALS AND METHODS A retrospective review of all patients who had standard APR between January 2000 and December 2016 in a single institution, Cabrini Hospital, Melbourne, Australia. A total of 163 cases performed by nine different colorectal surgeons for primary rectal adenocarcinoma were identified, with their clinicopathological data analysed. RESULTS Using standard APR, only six patients (3.7%) were found to have a positive circumferential resection margin (CRM). There were two cases of intra-operative perforation (1.2%). Local recurrence rate was 5.6% of patients, with distant recurrence found in 24.9%. Disease-free survival at five years was 73.1%. Five-year overall survival was 66.7%, 67.9% of all deaths were cancer-related. CONCLUSION Short and long-term outcomes after standard APR in this study were comparable to previous published studies. The CRM rate of 3.7% compares favourably to published positive CRM rates for standard APR which ranged from 6 to 18%. Standard APR remains a viable technique for the treatment of rectal cancer. Patient selection and adequate training remain important factors.
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Affiliation(s)
- S. Wilkins
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - R. Yap
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - K. Loon
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - M. Staples
- Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, VIC, Australia
| | - K. Oliva
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - B. Ruggiero
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - P. McMurrick
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - P. Carne
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Colorectal Unit, Department of Surgery, Alfred Hospital, Melbourne, VIC, Australia
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17
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Extralevator Abdominal Perineal Excision Versus Standard Abdominal Perineal Excision: Impact on Quality of the Resected Specimen and Postoperative Morbidity. World J Surg 2018; 41:2160-2167. [PMID: 28265736 DOI: 10.1007/s00268-017-3963-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Abdominal perineal excision (APE) has been associated with a high risk of positive circumferential resection margin (CRM+) and local recurrence rates in the treatment of rectal cancer. An alternative extralevator approach (ELAPE) has been suggested to improve the quality of resection by avoiding coning of the specimen decreasing the risk of tumor perforation and CRM+. The aim of this study is to compare the quality of the resected specimen and postoperative complication rates between ELAPE and "standard" APE. METHODS All patients between 1998 and 2014 undergoing abdominal perineal excision for primary or recurrent rectal cancer at a single Institution were reviewed. Between 1998 and 2008, all patients underwent standard APE. In 2009 ELAPE was introduced at our Institution and all patients requiring APE underwent this alternative procedure (ELAPE). The groups were compared according to pathological characteristics, specimen quality (CRM status, perforation and failure to provide the rectum and anus in a single specimen-fragmentation) and postoperative morbidity. RESULTS Fifty patients underwent standard APEs, while 22 underwent ELAPE. There were no differences in CRM+ (10.6 vs. 13.6%; p = 0.70) or tumor perforation rates (8 vs. 0%; p = 0.30) between APE and ELAPE. However, ELAPE were less likely to result in a fragmented specimen (42 vs. 4%; p = 0.002). Advanced pT-stage was also a risk factor for specimen fragmentation (p = 0.03). There were no differences in severe (Grade 3/4) postoperative morbidity (13 vs. 10%; p = 0.5). Perineal wound dehiscences were less frequent among ELAPE (52 vs 13%; p < 0.01). Despite short follow-up (median 21 mo.), 2-year local recurrence-free survival was better for patients undergoing ELAPE when compared to APE (87 vs. 49%; p = 0.04). CONCLUSIONS ELAPE may be safely implemented into routine clinical practice with no increase in postoperative morbidity and considerable improvements in the quality of the resected specimen of patients with low rectal cancers.
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18
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Law WL, Foo DCC. Surgical Results and Oncologic Outcomes for Rectal Cancer with Tailored Mesorectal Excision over Two Decades. World J Surg 2017; 40:1500-8. [PMID: 26801507 DOI: 10.1007/s00268-016-3408-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study aimed to compare the characteristics of the tumors, the management strategy, and oncologic outcomes of patients with rectal cancer surgery in these two periods: period 1 (1993-2001) and period 2 (2002-2011). METHODS All patients who underwent radical resection of rectal cancer from 1993 to 2011 were included. Comparisons of the patients' demographics, characteristics, operating results, and oncologic outcome between the two periods were undertaken. RESULTS Radical resection for rectal cancer was performed in 1611 patients (993 men). Patients were significantly older and more had comorbid medical diseases in period 2. More laparoscopic resections were performed and more patients had preoperative chemoradiation in period 2. The postoperative mortality was significantly lower and the hospital stay was significantly shorter in period 2. In those with non-metastatic cancer, the 5-year local recurrences of patients in period 1 and period 2 were 11.9 and 5.9 %, respectively. (p = 0.002) The patients in period 2 had significantly better 5-year overall (68.1 vs. 60.2 %, p = 0.003) and 5-year cancer-specific survival (76.1 vs. 69.4 %, p < 0.001) when compared with those treated in period 1. The improvement occurred mainly in patients with abdominoperineal resection and those with stage III diseases. In the multivariate analysis, among the other histological factors, operations performed in period 2 and laparoscopic surgery were independent factors associated with better overall survival. CONCLUSIONS Significant improvement in the surgical outcomes in terms of a lower recurrence rate and better survival was achieved in the recent years with the increase in neoadjuvant therapy and the application of laparoscopic surgery.
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Affiliation(s)
- Wai Lun Law
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
| | - Dominic C C Foo
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
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19
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Warschkow R, Ebinger SM, Brunner W, Schmied BM, Marti L. Survival after Abdominoperineal and Sphincter-Preserving Resection in Nonmetastatic Rectal Cancer: A Population-Based Time-Trend and Propensity Score-Matched SEER Analysis. Gastroenterol Res Pract 2017; 2017:6058907. [PMID: 28197206 PMCID: PMC5286526 DOI: 10.1155/2017/6058907] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/15/2016] [Indexed: 12/13/2022] Open
Abstract
Background. Abdominoperineal resection (APR) has been associated with impaired survival in nonmetastatic rectal cancer patients. It is unclear whether this adverse outcome is due to the surgical procedure itself or is a consequence of tumor-related characteristics. Study Design. Patients were identified from the Surveillance, Epidemiology, and End Results database. The impact of APR compared to coloanal anastomosis (CAA) on survival was assessed by Cox regression and propensity-score matching. Results. In 36,488 patients with rectal cancer resection, the APR rate declined from 31.8% in 1998 to 19.2% in 2011, with a significant trend change in 2004 at 21.6% (P < 0.001). To minimize a potential time-trend bias, survival analysis was limited to patients diagnosed after 2004. APR was associated with an increased risk of cancer-specific mortality after unadjusted analysis (HR = 1.61, 95% CI: 1.28-2.03, P < 0.01) and multivariable adjustment (HR = 1.39, 95% CI: 1.10-1.76, P < 0.01). After optimal adjustment of highly biased patient characteristics by propensity-score matching, APR was not identified as a risk factor for cancer-specific mortality (HR = 0.85, 95% CI: 0.56-1.29, P = 0.456). Conclusions. The current propensity score-adjusted analysis provides evidence that worse oncological outcomes in patients undergoing APR compared to CAA are caused by different patient characteristics and not by the surgical procedure itself.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
- Institute of Medical Biometry and Informatics, University of Heidelberg, 69120 Heidelberg, Germany
| | - Sabrina M. Ebinger
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
- Department of Surgery, Hospital of Thun, 3600 Thun, Switzerland
| | - Walter Brunner
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
| | - Bruno M. Schmied
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
| | - Lukas Marti
- Department of Surgery, Cantonal Hospital of St. Gallen, 9007 St. Gallen, Switzerland
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
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20
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Mörner MEM, Edgren G, Martling A, Gunnarsson U, Egenvall M. Preoperative anaemia and perioperative red blood cell transfusion as prognostic factors for recurrence and mortality in colorectal cancer-a Swedish cohort study. Int J Colorectal Dis 2017; 32:223-232. [PMID: 27770250 PMCID: PMC5285411 DOI: 10.1007/s00384-016-2678-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The hypothesis in this study was that anaemia prior to surgery and perioperative red blood cell transfusion increases the risk for recurrence and overall mortality in patients with stages I-III colorectal cancer after abdominal resection with curative intent. METHODS This is a Swedish single centre retrospective cohort study. Data on 496 consecutive radical abdominal resections stages I-III colorectal cancer performed at the Karolinska University Hospital 2007-2010 were extracted from the Swedish Colorectal Cancer Registry. Data were linked to local laboratory and transfusion databases to identify preoperative anaemia and perioperative transfusion. Disease recurrence was validated by scrutiny of patient records. A total of 496 stages I-III colorectal cancer patients were included in the analysis. Multivariate Cox regression analysis adjusted for tumour and patient characteristics were performed to assess risk for recurrence and overall mortality. RESULTS Anaemia prior to surgery was associated with increased risk for overall mortality (HR 2.1, 95% CI 1.4-3.2). There was no association between anaemia and risk for recurrence (HR 1.6, 95% CI 0.97-2.6). Transfusion was not associated with increased risk of recurrence (HR 0.7, 95% CI 0.4-1.3) or overall mortality (HR 1.04, 95% CI 0.7-1.6). CONCLUSIONS Anaemia prior to colorectal cancer surgery was associated with increased risk for overall mortality while a no increased risk was seen for recurrence. Previous findings indicating an association between blood transfusion and increased risk for recurrence could not be confirmed.
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Affiliation(s)
- Malin E. M. Mörner
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden ,Functional Area of Emergency Medicine Huddinge, C1:63, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,Center of Digestive Diseases, P9:03, Karolinska University Hospital, Solna, Sweden
| | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå university, Umeå, Sweden
| | - Monika Egenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,Center of Digestive Diseases, P9:03, Karolinska University Hospital, Solna, Sweden
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Lee KH, Kim JS, Kim JY. Long-term oncologic outcomes of neoadjuvant concurrent chemoradiotherapy with capecitabine and radical surgery in locally advanced rectal cancer: 10-year experiences at a single institution. Ann Surg Treat Res 2016; 91:178-186. [PMID: 27757395 PMCID: PMC5064228 DOI: 10.4174/astr.2016.91.4.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/22/2016] [Accepted: 09/05/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Oral capecitabine has demonstrated to be safe and efficient as neoadjuvant concurrent chemoradiotherapy (NCRT) for locally advanced rectal cancers. The aim of this study was to evaluate the long-term oncologic outcomes of NCRT with capecitabine and radical surgery. METHODS From January 2000 to June 2010, 238 patients were treated at our center for locally advanced rectal cancers using conventional NCRT with capecitabine and radical surgery. Univariate and multivariate analyses were used to evaluate the factors associated with oncologic outcomes with log rank and Cox regression tests. RESULTS The incidence of grade >3 capecitabine-related toxicity was found to be 4.6%. A pathologic complete response was observed in 14.7% of patients. The 5-year overall and 5-year disease-free survival rate, local and systemic recurrence rate were 82.8%, 75.1%, 4.8%, and 20.3%. Abdominoperineal resection and node-positive disease were independent prognostic factors of 5-year overall survival, 5-year disease-free survival, and systemic recurrence. CONCLUSION NCRT with capecitabine and radical surgery showed favorable long-term oncologic outcomes with benefits of acceptable toxicity and convenience. We suggest that capecitabine can be one of the favorable therapeutic options for NCRT in rectal cancer.
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Affiliation(s)
- Kyung Ha Lee
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
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22
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Negoi I, Hostiuc S, Paun S, Negoi RI, Beuran M. Extralevator vs conventional abdominoperineal resection for rectal cancer-A systematic review and meta-analysis. Am J Surg 2016; 212:511-26. [PMID: 27317475 DOI: 10.1016/j.amjsurg.2016.02.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/23/2016] [Accepted: 02/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to compare the short-term morbidity and long-term oncologic benefits of extralevator abdominoperineal excision (ELAPE) with conventional abdominoperineal resection (CAPR) for patients with rectal cancer. METHODS Electronic search of the Cochrane Library, MEDLINE, EMBASE, Korean Journal, and J-EAST database from 2007 until August 2015 was carried out. We considered randomized controlled trials and nonrandomized comparative studies comparing ELAPE with CAPR to be eligible, if they included patients with rectal cancers. RESULTS A total of 1 randomized controlled trials and 10 nonrandomized comparative studies met the inclusion criteria, involving 1,736 patients in the ELAPE group and 1,320 in the CAPR group. The ELAPE was associated with a significantly lower intraoperative perforation rate. There were no differences regarding the circumferential margin involvement, R0 resections, and local recurrence rate. There was less blood loss in ELAPE patients. CONCLUSIONS The ELAPE significantly lowered the intraoperative perforation rate, with no benefits regarding circumferential resection margin involvement and local recurrence rate.
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Affiliation(s)
- Ionut Negoi
- General Surgery Department, Carol Davila University of Medicine and Pharmacy Bucharest, No. 37 Dionisie Lupu Street, Sector 2, 020021, Bucharest, Romania; General Surgery Department, Emergency Hospital of Bucharest, Bucharest, Romania.
| | - Sorin Hostiuc
- General Surgery Department, Carol Davila University of Medicine and Pharmacy Bucharest, No. 37 Dionisie Lupu Street, Sector 2, 020021, Bucharest, Romania; National Institute of Legal Medicine Mina Minovici, Bucharest, Romania
| | - Sorin Paun
- General Surgery Department, Carol Davila University of Medicine and Pharmacy Bucharest, No. 37 Dionisie Lupu Street, Sector 2, 020021, Bucharest, Romania; General Surgery Department, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Ruxandra I Negoi
- Anatomy Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mircea Beuran
- General Surgery Department, Carol Davila University of Medicine and Pharmacy Bucharest, No. 37 Dionisie Lupu Street, Sector 2, 020021, Bucharest, Romania; General Surgery Department, Emergency Hospital of Bucharest, Bucharest, Romania
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De Nardi P, Summo V, Vignali A, Capretti G. Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis. Ann Surg Oncol 2015; 22:2997-3006. [PMID: 25605518 DOI: 10.1245/s10434-015-4368-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Indexed: 12/27/2024]
Abstract
BACKGROUND The extended, extralevator abdominoperineal excision has been described with the aim of improving oncological low rectal cancer patient outcomes. MATERIALS AND METHODS A systematic literature review was conducted using Medline/PubMed, Embase, Cochrane library, and Ovid for standard and extralevator abdominoperineal rectal cancer excision studies between 1995 and 2013. A total of 1,270 articles were identified and screened, and of these, 58 reports (1 randomized, 5 case-control and 52 cohort studies) were included for the qualitative analysis, and 6 were included for the quantitative analysis. The primary endpoints included intraoperative tumor perforation, the circumferential resection margin involvement, local recurrence rate, and the perineal wound complication rate. The secondary endpoints included the length of postoperative hospital stay and quality of life. Comprehensive Rev Men, version 5.2 was used for the statistical calculations. RESULTS A significant difference in the circumferential resection margin involvement rate [odds ratio (OR) 2.9; p < .001], intraoperative perforation (OR 4.30; p < .001), local recurrence rate (OR 2.52; p = .02), and length of hospital stay (OR 1.06; p < .001) in favor of the extended group was observed. Additionally, the perineal wound complications were higher in the extended group (OR 0.62; p = .007). No difference in quality of life was observed. CONCLUSIONS Our analysis confirms the oncological advantages of the extended abdominoperineal excision method. Although the perineal wound complications were higher, the length of postoperative hospital stay was shorter, and quality of life was not inferior to the conventional resection method.
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Affiliation(s)
- Paola De Nardi
- Department of Surgery, San Raffaele Scientific Institute, Milan, Italy,
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Liu P, Bao H, Zhang X, Zhang J, Ma L, Wang Y, Li C, Wang Z, Gong P. Better operative outcomes achieved with the prone jackknife vs. lithotomy position during abdominoperineal resection in patients with low rectal cancer. World J Surg Oncol 2015; 13:39. [PMID: 25889121 PMCID: PMC4331390 DOI: 10.1186/s12957-015-0453-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 01/08/2015] [Indexed: 12/21/2022] Open
Abstract
Background Lithotomy (LT) and prone jackknife positions (PJ) are routinely used for abdominoperineal resection (APR). The present study compared the clinical, pathological, and oncological outcomes of PJ-APR vs. LT-APR in low rectal cancer patients in order to confirm which position will provide more benefits to patients undergoing APR. Methods This is a retrospective study of consecutive patients with low rectal cancer who underwent curative APR between January 2002 and December 2011. Patients were matched 1:2 (PJ-APR = 74 and LT-APR = 37 patients) based on gender and age. Perioperative data, postoperative outcomes, and survival were compared between the two approaches. Results Hospital stay was shorter with PJ-APR compared with LT-APR (P < 0.05). Compared with LT-APR, duration of anesthesia (234 ± 50.8 vs. 291 ± 69 min, P = 0.022) and surgery (183 ± 44.8 vs. 234 ± 60 min, P = 0.016) was shorter with PJ-APR, and estimated blood losses were smaller (549 ± 218 vs. 674 ± 350 mL, P < 0.001). Blood transfusions were required in 37.8% of LT-APR patients and in 8.1% of PJ-APR patients (P < 0.001). There was no difference in the distribution of N stages (P = 0.27). Median follow-up was 47.1 (13.6–129.7) months. Postoperative complications were reported by fewer patients after PJ-APR compared with LT-APR (14.9% vs. 32.4%, P = 0.030). There were no significant differences in overall survival, disease-free survival, local recurrence, and distant metastasis (P > 0.05). Conclusions The PJ position provided a better exposure for low rectal cancer and had a lower operative risk and complication rates than LT-APR. However, there was no difference in rectal cancer prognosis between the two approaches. PJ-APR might be a better choice for patients with low rectal cancer.
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Affiliation(s)
- Peng Liu
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Haidong Bao
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Xianbin Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Jian Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Li Ma
- Department of Epidemiology, Dalian Medical University, 9 Lvshun Road South, 116044, Dalian, China.
| | - Yulin Wang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Chunyan Li
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Zhongyu Wang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
| | - Peng Gong
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, 116011, Dalian, China.
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Shen Z, Ye Y, Zhang X, Xie Q, Yin M, Yang X, Jiang K, Liang B, Wang S. Prospective controlled study of the safety and oncological outcomes of ELAPE procure with definitive anatomic landmarks versus conventional APE for lower rectal cancer. Eur J Surg Oncol 2015; 41:472-7. [PMID: 25659773 DOI: 10.1016/j.ejso.2015.01.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/19/2015] [Accepted: 01/22/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The use of extra-levator abdominoperineal resection (ELAPE) procedure for lower rectal cancer is controversial. It is unclear whether the ELAPE procedure could improve surgical safety and lead to better oncological outcomes. METHODS Sixty-nine lower rectal cancer patients who underwent ELAPE (36 cases) or conventional abdominoperineal resection (APE; 33 cases) between June 2011 and February 2013 were prospectively investigated. Clinicopathological variables including blood loss, intraoperative perforation (IOP) rate, circumferential resection margin (CRM) involvement, lymph node harvest, the postoperative complications, urinary and sexual function, quality of life (QOL), local recurrence rate and survival were recorded and compared. RESULTS Blood loss (P = 0.021), perineal wound complication (P = 0.039), IOP rate (P = 0.028), local recurrence (P = 0.034) were significantly less frequent in the ELAPE group. There was greater CRM involvement in the conventional APE group but no statistical difference between the two groups. Urinary function, sexual function and QOL were not significantly different between the two groups. Overall survival and progression-free survival were not significantly different between two groups, even when survival was analyzed according to TNM stage, T stage, N stage, and with or without neoadjuvant chemoradiotherapy. In patients who underwent ELAPE there was no statistical difference in postoperative complications between younger and elderly patients (age ≥60). CONCLUSIONS ELAPE procedure with definitive anatomic landmarks demonstrated surgical safety and decreased local recurrence for lower rectal cancer patients including the elderly, but there were no survival improvements in compared to conventional APE procedure.
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Affiliation(s)
- Z Shen
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - Y Ye
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China.
| | - X Zhang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - Q Xie
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - M Yin
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - X Yang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - K Jiang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - B Liang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China
| | - S Wang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, PR China.
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Improved quality of care for patients undergoing an abdominoperineal excision for rectal cancer. Eur J Surg Oncol 2014; 41:201-7. [PMID: 25572974 DOI: 10.1016/j.ejso.2014.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 10/13/2014] [Accepted: 11/06/2014] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION New diagnostics, the emergence of total mesorectal excision and neoadjuvant treatments have improved outcome for patients with rectal cancer. Patients with distal rectal cancer undergoing an abdominoperineal excision seem to do worse compared to those treated with sphinctersparing techniques. The aim of this study was to evaluate the quality of care for patients undergoing an abdominoperineal excision for distal rectal cancer during the last 15 years. MATERIALS AND METHODS All patients with rectal cancer, who underwent an abdominoperineal excision between December 1996 and December 2010 in 5 Dutch hospitals were analysed. Patients were divided into three cohorts; 1996-2001, 2001-2005 and 2006-2010. All data was extracted from medical records. RESULTS 477 patients were identified. There was no significant difference in sex, age, BMI, prior pelvic surgery and ASA stages between the cohorts. MRI became a standard tool in the work-up, the use increased from 4.5% in the first, to 95.1% in the last cohort (p < 0.0001). Neoadjuvant treatment shifted from predominantly none (64.9% in cohort 1) to short course radiotherapy (66.7% in cohort 2) and chemoradiation therapy (55.7% in cohort 3). There was a trend towards a decreased circumferential resection margin involvement in the cohorts (18.8%, 16.7% and 11.4%; p = 0.142). Accidental bowel perforations have significantly decreased from 28.6%, and 21.7% to 9.2% in cohort 3 (p < 0.0001). CONCLUSION Significant improvements in work-up, neoadjuvant and surgical treatment have been made for patients with low rectal cancer, undergoing an abdominoperineal excision. These improvements result in improved short term outcome.
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Bisschop C, Tjalma JJJ, Hospers GAP, Van Geldere D, de Groot JWB, Wiegman EM, Van’t Veer-ten Kate M, Havenith MG, Vecht J, Beukema JC, Kats-Ugurlu G, Mahesh SVK, van Etten B, Havenga K, Burgerhof JGM, de Groot DJA, de Vos tot Nederveen Cappel WH. Consequence of Restaging After Neoadjuvant Treatment for Locally Advanced Rectal Cancer. Ann Surg Oncol 2014; 22:552-6. [DOI: 10.1245/s10434-014-3996-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Indexed: 11/18/2022]
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Pollett WG, Gibbs P, McLaughlin S, Eteuati J, Harold M, Marion K, Patel S, Jones I. Outcomes in the surgical treatment of low rectal cancer: does neoadjuvant treatment equalize results? ANZ J Surg 2014; 85:140-4. [PMID: 25091124 DOI: 10.1111/ans.12786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND The choice of operation for potentially curable cancer of the low rectum (≤6 cm from the anal verge) is usually between ultra low anterior resection (ULAR) or abdominal perineal excision (APE). Numerous studies have suggested improved results with ULAR. METHODS This study was a retrospective review of prospectively collected data for a series of patients undergoing surgical treatment for low rectal cancer at three Melbourne hospitals. The patient details and outcomes were compared between those undergoing APE and ULAR. RESULTS One hundred and ninety-eight of 213 patients with potentially curable low rectal cancer were treated by either ULAR (n = 82) or APE (n = 116). Overall survival and local recurrence rates were similar, although there was a trend towards improved results for ULAR. Preoperative radiation was received by 89 (76.7%) of APE patients and 44 (53.7%) of ULAR patients (P < 0.0005). CONCLUSION In this study there was no statistical difference in the oncological results between APE and ULAR. However, there was a trend to improved result for ULAR in spite of a strikingly higher rate of neoadjuvant radiation in the APE group. It is possible that enhanced use of preoperative radiation has a beneficial role in the management of low rectal cancer treated by conventional APE.
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Affiliation(s)
- William G Pollett
- Discipline of Surgery, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Wang L, Gu GL, Li ZW, Peng YF, Gu J. Abdominoperineal excision following preoperative radiotherapy for rectal cancer: unfavorable prognosis even with negative circumferential resection margin. World J Gastroenterol 2014; 20:9138-9145. [PMID: 25083087 PMCID: PMC4112869 DOI: 10.3748/wjg.v20.i27.9138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/10/2014] [Accepted: 04/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate whether an abdominoperineal excision (APE) is associated with increased local recurrence (LR) and shortened disease-free survival (DFS) in mid-low rectal cancer with a negative circumferential resection margin (CRM). METHODS 283 consecutive cases of mid-low rectal cancer underwent preoperative 30 Gy/10 F radiotherapy and surgery in Peking University Cancer Hospital between August 2003 and August 2009. Patients with positive CRM and intraoperative distant metastasis were precluded according to exclusion criteria. Survival analyses were performed in patients with APE or non-APE procedures. RESULTS 256 of the 283 (90.5%) cases were enrolled in the analysis, including 78 (30.5%) and 178 (69.5%) cases who received APE and non-APE procedures. Fewer female patients (P = 0.016), lower level of tumor (P = 0.000) and higher body mass index (P = 0.006) were found in the APE group. On univariate analysis, the APE group had a higher LR rate (5.1% vs 1.1%, P = 0.036) and decreased DFS (73.1% vs 83.4%, P = 0.021). On multivariate analysis, APE procedure was also an independent risk factor for LR (HR = 5.960, 1.085-32.728, P = 0.040) and decreased DFS (HR = 2.304, 1.298-4.092, P = 0.004). In stratified analysis for lower rectal cancer, APE procedure was still an independent risk factor for higher LR rate (5.6% vs 0%, P = 0.024) and shortened DFS (91.5% vs 73.6%, P = 0.002). CONCLUSION Following preoperative 30 Gy/10 F radiotherapy, APE procedure was still a predictor for LR and decreased DFS even with negative CRM. More intensive preoperative treatment should be planned for the candidates who are scheduled to receive APE with optimal imaging assessment.
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Circumferential resection margins of rectal tumours post-radiotherapy: how can MRI aid surgical planning? Tech Coloproctol 2014; 18:937-43. [DOI: 10.1007/s10151-014-1199-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 02/11/2014] [Indexed: 01/01/2023]
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Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 2014; 29:321-7. [PMID: 24385025 DOI: 10.1007/s00384-013-1794-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively. METHODS An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel-Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI). RESULTS Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23-0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12-0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08-0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses. CONCLUSIONS Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.
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Jorgensen ML, Young JM, Dobbins TA, Solomon MJ. Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery. Br J Surg 2013; 100:1655-63. [DOI: 10.1002/bjs.9293] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators.
Methods
Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots.
Results
A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15·9 (95 per cent confidence interval (c.i.) 14·2 to 17·6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38·2 (34·6 to 41·8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = −0·55, P = 0·019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2·14, 95 per cent c.i. 1·11 to 4·15).
Conclusion
APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.
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Affiliation(s)
- M L Jorgensen
- Cancer Epidemiology and Services Research, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - J M Young
- Cancer Epidemiology and Services Research, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre, Sydney Local Health District and University of Sydney, Sydney, New South Wales, Australia
| | - T A Dobbins
- Cancer Epidemiology and Services Research, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre, Sydney Local Health District and University of Sydney, Sydney, New South Wales, Australia
- Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia
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Omidvari S, Hamedi SH, Mohammadianpanah M, Razzaghi S, Mosalaei A, Ahmadloo N, Ansari M, Pourahmad S. Comparison of abdominoperineal resection and low anterior resection in lower and middle rectal cancer. J Egypt Natl Canc Inst 2013; 25:151-60. [DOI: 10.1016/j.jnci.2013.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/12/2013] [Accepted: 06/15/2013] [Indexed: 01/23/2023] Open
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Toshniwal S, Perera M, Lloyd D, Nguyen H. A 12-year experience of the Trendelenburg perineal approach for abdominoperineal resection. ANZ J Surg 2013; 83:853-8. [DOI: 10.1111/ans.12137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2013] [Indexed: 01/21/2023]
Affiliation(s)
| | | | - David Lloyd
- Launceston General Hospital; Launceston Tasmania Australia
| | - Hung Nguyen
- Launceston General Hospital; Launceston Tasmania Australia
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Welsch T, Mategakis V, Contin P, Kulu Y, Büchler MW, Ulrich A. Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications. Int J Colorectal Dis 2013. [PMID: 23178992 DOI: 10.1007/s00384-012-1611-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Extralevator abdominoperineal resection (APR) for low rectal cancer has been adopted by centers to improve oncological outcome. The present study aimed to investigate oncological results, wound complications, and quality of life (QoL). METHODS Patients who underwent extralevator APR for rectal cancer between 2007 and 2011 were identified retrospectively. QoL status was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR30 and CR29 questionnaires. RESULTS Thirty laparoscopic (n = 7) or open (n = 23) extralevator APRs were performed in 17 male and 13 female patients. The mortality was zero; circumferential margin involvement occurred in two cases (6.7 %); and there was no bowel perforation. No local recurrence was noted after a median follow-up of 28.3 months; however, six patients died, and eight developed distant metastases. Perineal wound complications were found in 46.6 % of patients, and all were managed conservatively. Fifty percent of the patients reported persistent perineal pain at the follow-up exam. QoL was assessed 7 to 46 months after surgery, and the global health status (70.6) was comparable to the EORTC reference group and published conventional APR series. The QLQ-CR29 module revealed high mean symptom scores for urinary frequency (48.1), incontinence (30.5), and impotence (79.1). CONCLUSIONS Extralevator APR can control local recurrence but not distant metastases of low rectal cancer. The extended perineal resection appears not to decrease general QoL, but it results in a high rate of perineal wound complications. Genitourinary functions are often impaired, even in the long term, and further improvements to the technique must seek to reduce genitourinary harm.
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Affiliation(s)
- Thilo Welsch
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Liang JT, Cheng JCH, Huang KC, Lai HS, Sun CT. Comparison of tumor recurrence between laparoscopic total mesorectal excision with sphincter preservation and laparoscopic abdominoperineal resection for low rectal cancer. Surg Endosc 2013; 27:3452-64. [PMID: 23508815 DOI: 10.1007/s00464-013-2898-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 02/15/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND By traditional open surgery, the tumor recurrence rate of total mesorectal excision with sphincter-preserving procedure was lower than that of abdominoperineal resection (APR) for the treatment of low rectal cancer. The present study aimed to rescrutinize whether the same conclusion can be drawn when both surgical procedures are performed laparoscopically. METHODS We retrospectively reviewed the prospectively recorded clinicopathologic data of 344 consecutive patients with low rectal cancer, in which 170 patients underwent preoperative chemoradiotherapy followed by laparoscopic total mesorectal excision (TME), whereas 174 patients underwent laparoscopic TME directly without chemoradiotherapy. Such patients were further stratified according to the pathologic tumor, node, metastasis stage (stage II or III disease) and surgical strategy (APR or sphincter-preserving operation [SPO]). The surgical procedures are presented in supplemental videos. The disease-free survival, recurrence patterns, and functional recovery of patient groups stratified as appropriate were compared. RESULTS In patients who received preoperative chemoradiotherapy, the estimated recurrence rate were similar between laparoscopic TME with SPO and laparoscopic APR with 10.6%, 7 of 66, versus 18.5%, 5 of 27, in stage II disease (p = 0.811, log-rank test); and 19.3%, 11 of 57, versus 20%, 4 of 20, in stage III disease (p = 0.980). In patients without preoperative chemoradiotherapy, the recurrence rate was significantly higher in laparoscopic APR than in the laparoscopic TME with SPO group of patients with stage III disease (45%, 9 of 20, vs. 19.3%, 16 of 83, p = 0.025), whereas the recurrence rate of the two procedures was similar (21.4%, 3 of 14, vs. 17.5%, 10 of 57, p = 0.702) in stage II disease. CONCLUSIONS When low rectal cancer was operated on by laparoscopic approach, the poorer prognosis of APR compared to SPO was only observed in stage III patients without preoperative chemoradiotherapy.
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Affiliation(s)
- Jin-Tung Liang
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital, and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan.
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Kim NK, Kim MS, Al-Asari SF. Update and debate issues in surgical treatment of middle and low rectal cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012. [PMID: 23185702 PMCID: PMC3499423 DOI: 10.3393/jksc.2012.28.5.230] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Based on a review of the literature, this paper provides an update on surgical treatment of middle and low rectal cancer and discusses issues of debate surrounding that treatment. The main goal of the surgical treatment of rectal cancer is radical resection of the tumor and surrounding lymphatic tissue. Local excision of early rectal cancer can be another treatment option, in which the patient can avoid possible complications related to radical surgery. Neoadjuvant chemoradiation therapy (CRT) has been recommended for patients with cT3-4N0 or any T N+ rectal cancer because CRT shows better local control and less toxicity than adjuvant CRT. However, recent clinical trials showed promising results for local excision after neoadjuvant CRT in selected patients with low rectal cancer. In addition, the "wait and see" concept is another modality that has been reported for the management of tumors that show complete clinical remission after neoadjuvant CRT. Although radical surgery for middle and low rectal cancer is the cornerstone therapy, an ultralow anterior resection with or without intersphincteric resection (ISR) has become an alternative standard surgical method for selected patients. Many studies have reported on the oncological safety of the ISR, but few of them have addressed the issue the functional outcome. Furthermore, an abdominoperineal resection (APR) has problems with high rates of tumor perforations and positive circumferential resection margins, and those factors have contributed to its having a high rate of local recurrence and a poor survival rate for rectal cancer compared with sphincter-saving procedures. Recently, great efforts have been made to reduce these problems, and the total levator excision or the extended APR concept has emerged. Surgical management for low rectal cancer should aim to radically excise the tumor and to preserve as much of the sphincter function as possible by using multidisciplinary approaches. However, further prospective clinical trials are needed for tailored treatment of rectal cancer patients.
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Affiliation(s)
- Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 2012; 204:274-282. [PMID: 22920402 DOI: 10.1016/j.amjsurg.2012.05.001] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 05/18/2012] [Accepted: 05/18/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND An alternative treatment for low rectal cancer is the cylindrical technique. We aim to compare the outcomes of patients undergoing conventional abdominoperineal resection (APR) versus cylindrical APR. METHODS A prospective, randomized, open-label, parallel controlled trial was conducted between January 2008 and December 2010. Sixty-seven patients with T3-T4 low rectal cancer were identified during the study period (conventional n = 32, cylindrical n = 35). RESULTS Patients who received cylindrical APR had less operative time for the perineal portion (P < .001), larger perineal defect (P < .001), less intraoperative blood loss (P = .001), larger total cross-sectional tissue area (P < .001), similar total operative time (P = .096), and more incidence of perineal pain (P < .001). The local recurrence of the cylindrical APR group was improved statistically (P = .048). CONCLUSIONS Cylindrical APR in the prone jackknife position has the potential to reduce the risk of local recurrence without increased complications when compared with conventional APR in the lithotomy position for the treatment of low rectal cancer.
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Affiliation(s)
- Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Gezen C, Altuntas YE, Kement M, Aksakal N, Okkabaz N, Vural S, Oncel M. Laparoscopic and conventional resections for low rectal cancers: a retrospective analysis on perioperative outcomes, sphincter preservation, and oncological results. J Laparoendosc Adv Surg Tech A 2012; 22:625-30. [PMID: 22731804 DOI: 10.1089/lap.2011.0479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This study aims to compare the results of laparoscopic and conventional techniques in patients with low rectal cancers. SUBJECTS AND METHODS A retrospective data analysis was initiated in patients underwent laparoscopic or conventional surgery for cancers located in the low (<6 cm) rectum. Patient and tumor-related information, outcomes of operations, and survival were compared between the groups. RESULTS Among 142 patietns (91 men [64.1%]; mean±standard deviation age, 57.7±14.6 years) who had tumors located <6 cm from the dentate line, 92 (64.8%) were operated on with the laparoscopic technique. Demographics, tumor stage, and localization (2.9±2.0 versus 2.9±2.1 cm from the dentate line in laparoscopic and conventional arms, respectively; P=.968) were similar. However, there were more patients in the laparoscopic group who received neoadjuvant chemoradiation therapy (92.4% versus 80.0%; P=.03), since there were significantly fewer cases with stage I tumors in this group (3.3% versus 14%; P=.33). The conversion rate was 14.1% (n=13). The amount of bleeding and the requirement for transfusion decreased (P<.05 for both), and the possibility of sphincter-saving procedures (66.3% versus 34.0%; P<.001) increased, in the laparoscopy group. Other parameters were identical. In the laparoscopy group, the number of harvested lymph nodes (10.2±5.4 versus 12.4±6.0; P=.025) and the rate of vascular invasion (27.5% versus 47.8%; P=.021) were less, and Kaplan-Meier analysis revealed an improved survival (P=.042), although the follow-up period was significantly shorter in this group (P<.001). CONCLUSIONS Laparoscopic surgery for low rectal cancers may be technically feasible and oncologically safe. Laparoscopy may increase the possibility of sphincter preservation.
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Affiliation(s)
- Cem Gezen
- General Surgery Department, Kartal Education and Research Hospital, Istanbul, Turkey.
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Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only? Dis Colon Rectum 2012; 55:51-8. [PMID: 22156867 DOI: 10.1097/dcr.0b013e3182351c1f] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous reports suggest that patients with rectal cancer undergoing abdominoperineal resection have worse oncologic outcomes in comparison with those undergoing restorative rectal resection. OBJECTIVE This study aimed to assess factors influencing oncologic outcomes for patients undergoing surgery for rectal cancer. DESIGN This study is a retrospective review of prospectively gathered data. SETTING Data were gathered from a prospective cancer database. PATIENTS Patients were included who underwent radical resection for mid and lower third rectal cancer (1991-2006). MAIN OUTCOME MEASURES The primary outcomes measured were the impact of various factors on perioperative outcomes, local recurrence, and disease-free survival for patients undergoing abdominoperineal resection. RESULTS Four hundred thirteen (29%) patients underwent abdominoperineal resection and 993 (71%) underwent restorative resection for rectal cancer. Patients with abdominoperineal resection were older (p < 0.0001), had a higher mean ASA score (p < 0.001), worse tumor differentiation (p < 0.001), and higher tumor stage (p = 0.0001). Although overall morbidity was lower in the abdominoperineal resection group (p = 0.001), the length of stay was greater (p < 0.001). After a similar period of follow-up (5.2 ± 3.9 vs 5.3 ± 3.4 y, p = 0.58), local recurrence (7% vs 3%, p = 0.02) was higher after abdominoperineal resection, but overall survival (56% vs 71%, p < 0.001) and disease-free survival (54% vs 70%, p < 0.001) were lower. On multivariate analysis, higher stage, poor tumor differentiation, involved margins, and older age were associated with worse survival, whereas higher stage, poor tumor differentiation, and abdominoperineal resection were associated with greater recurrence. These worse oncologic outcomes persisted even when the groups were stratified based on the location of the cancer in mid or distal rectum and for patients with a clear circumferential margin. LIMITATION This study was limited by its retrospective nature. CONCLUSION Technical factors alone are unlikely to be responsible for the worse outcomes after abdominoperineal resection in comparison with restorative resection. A combination of patient- and tumor-related factors that may have indicated the choice of the procedure also probably contribute to the worse outcomes. Because patients undergoing abdominoperineal resection represent a high risk for poor outcomes, management strategies need to consider all these factors during treatment.
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How P, Shihab O, Tekkis P, Brown G, Quirke P, Heald R, Moran B. A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era. Surg Oncol 2011; 20:e149-55. [PMID: 21632237 DOI: 10.1016/j.suronc.2011.05.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/04/2011] [Accepted: 05/05/2011] [Indexed: 01/29/2023]
Abstract
PURPOSE It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE. METHODS A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected. RESULTS Twenty four studies fulfilled the eligibility criteria with Newcastle-Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE. CONCLUSIONS Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced.
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Affiliation(s)
- P How
- Pelican Cancer Foundation, The Ark, Dinwoodie Drive, Basingstoke, RG24 9NN, UK.
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Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H. Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer--a systematic overview. Int J Colorectal Dis 2011; 26:1227-40. [PMID: 21603901 DOI: 10.1007/s00384-011-1235-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence. METHODS A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics. RESULTS In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups. CONCLUSION This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.
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Affiliation(s)
- Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany.
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Ludwig K, Kosinski L. How low is low? Evolving approaches to sphincter-sparing resection techniques. Semin Radiat Oncol 2011; 21:185-95. [PMID: 21645863 DOI: 10.1016/j.semradonc.2011.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although advances in rectal cancer staging may ultimately be accurate enough to reliably exclude disease outside the rectal wall (thereby allowing local approaches to be more widely and safely applied) and advances in the use of neoadjuvant chemo- and radiation therapy may ultimately produce more "complete responders" that can be accurately identified and spared surgery altogether, as it stands, radical resection forms the basis of curative treatment for rectal cancer. However, the concepts that guide the surgeon in choosing the optimal approach in radical resection are changing. In the past, the decision as to how to proceed surgically with radical resection was based primarily on the level of the tumor above the anal verge or anorectal ring. The issue was primarily "How low is the tumor?" and "Is the distal margin safe?" A more modern approach focuses attention on achieving a negative circumferential margin despite what historically may seem to be a very minimal distal margin, the current issue is not "How low is the tumor?" so much as it is "How deep does the tumor go?". This shift in focus has been a major impetus in the evolution of sphincter sparing resection techniques.
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Affiliation(s)
- Kirk Ludwig
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Low rectal cancer: abdominoperineal resection or low Hartmann resection? A postoperative outcome analysis. Dis Colon Rectum 2011; 54:958-62. [PMID: 21730783 DOI: 10.1097/dcr.0b013e31821c4b95] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In distal rectum cancers, when the sphincters are not affected and it is not possible to perform a coloanal anastomosis because of the presence of comorbidities or the advanced age of the patient, a low Hartmann resection with total mesorectal excision can be performed. Low Hartmann resection is usually considered to be a shorter procedure and to have an inferior morbidity compared with abdominoperineal resection of the rectum. OBJECTIVE This study aimed to compare the postoperative outcome of a series of patients with low rectal cancer who have undergone either low Hartmann resection or abdominoperineal resection. DESIGN This study is a retrospective analysis of data collected in a prospective database. SETTINGS This study was conducted in a specialized Colorectal Unit, Department of Surgery, of a tertiary teaching hospital. PATIENTS Patients who underwent low Hartmann or abdominoperineal resection for rectal cancer between 1996 and 2009 at our specialized Colorectal Unit were considered. INTERVENTIONS The main interventions were low Hartmann resection vs abdominoperineal resection. MAIN OUTCOME MEASURES The main outcome measures were 60-day morbidity and mortality. RESULTS The pelvic abscess rate was 12.2% in patients who underwent low Hartmann resection and 3.0% in those who underwent abdominoperineal resection (P = .02). The reoperation rate was 14.6% in the Hartmann group and 3.8% in the abdominoperineal group (P = .013). The rehospitalization rates in the Hartmann and abdominoperineal groups were 7.3% and 0.7% (P = .015). No differences were found in the other variables analyzed. At multivariate analysis, the surgical technique performed was the only independent risk factor for pelvic abscess development, readmission, and reoperation. LIMITATIONS : This study was limited by its retrospective nature. CONCLUSION In our series, low Hartmann resection was associated with higher pelvic abscess, reoperation, and readmission rates. These findings suggest that in patients with rectal cancer without sphincter infiltration and who are unsuitable for coloanal anastomosis, abdominoperineal resection should be a valid alternative to low Hartmann resection.
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The current abdominoperineal resection: oncological problems and surgical modifications for low rectal cancer. J Visc Surg 2011; 148:e85-93. [PMID: 21481666 DOI: 10.1016/j.jviscsurg.2011.03.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abdominoperineal resection is the one of the oldest surgical procedures for rectal cancer. Outcome after abdominoperineal resection for rectal carcinoma is not as good as anterior resection as the risk of local recurrence is higher and survival is poorer. During abdominoperineal resection, the rate of rectal perforation is high and the circumferential margin is often involved. Recently the concept of cylindrical abdominoperineal resection has been reintroduced. It allows a large excision and the initial results are encouraging. The purpose of this article was to analyse the oncological results of abdominoperineal resection and to develop the potential technical modifications of the procedure.
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Mauvais F, Sabbagh C, Brehant O, Viart L, Benhaim T, Fuks D, Sinna R, Regimbeau JM. Amputation abdomino-périnéale dans la prise en charge des cancers du bas rectum (1) : problématique carcinologique et technique d’exérèse. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.jchirv.2010.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Silberfein EJ, Kattepogu KM, Hu CY, Skibber JM, Rodriguez-Bigas MA, Feig B, Das P, Krishnan S, Crane C, Kopetz S, Eng C, Chang GJ. Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol 2010; 17:2863-9. [PMID: 20552409 PMCID: PMC3071558 DOI: 10.1245/s10434-010-1119-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of distal rectal cancer remains clinically challenging and includes proctectomy and coloanal anastomosis (CAA) or abdominoperineal resection (APR). The purpose of this study is to evaluate operative and pathologic factors associated with long-term survival and local recurrence outcomes in patients treated for distal rectal cancer. METHODS A retrospective consecutive cohort study of 304 patients treated for distal rectal cancer with radical resection from 1993 to 2003 was performed. Patients were grouped by procedure (CAA or APR). Demographic, pathologic, recurrence, and survival data were analyzed utilizing chi-square analysis for comparison of proportions. Survival analysis was performed using Kaplan-Meier method and log-rank test for univariate and Cox regression for multivariate comparison. RESULTS The median tumor distance from the anal verge was 2 cm [interquartile range (IQR) 0.5-4 cm]. Margins were negative in all but four patients (one distal, 0.3%; three radial, 1%). The 5-year overall survival rate was 82% (88.6% stage pI, 80.5% stage pII, 67.9% stage pIII). Older age, advanced pathologic stage, presence of lymphovascular or perineural invasion, earlier treatment period, and APR surgery type were associated with worse survival on multivariate analysis. The 5-year local recurrence rate was 5.3% after CAA and 7.9% after APR (p = 0.33). CONCLUSIONS Low rates of local recurrence and good overall survival can be achieved after treatment of distal rectal cancer with stage-appropriate chemoradiation and proctectomy with CAA or APR. Sphincter preservation can be achieved even with distal margins less than 2 cm.
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Affiliation(s)
- Eric J Silberfein
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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van Dijk TH, Wiggers T, Havenga K. Abdominoperineal Resections for Rectal Cancer: Reducing the Risk of Local Recurrence. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Künzli BM, Friess H, Shrikhande SV. Is laparoscopic colorectal cancer surgery equal to open surgery? An evidence based perspective. World J Gastrointest Surg 2010; 2:101-8. [PMID: 21160858 PMCID: PMC2999223 DOI: 10.4240/wjgs.v2.i4.101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 03/03/2010] [Accepted: 03/10/2010] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic colorectal surgery (LCS) is an evolving subject. Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures. Fewer perioperative complications and faster postoperative recovery are regularly mentioned when studies of LCS are presented. Even though the learning curve of LCS is frequently debated when limitations of laparoscopic surgeries are reviewed, studies show that in experienced hands LCS can be a safe procedure for colorectal cancer treatment. The learning curve however, is associated with high conversion rates and economical aspects such as higher costs and prolonged hospital stay. Nevertheless, laparoscopic colorectal cancer surgery (LCCR) offers several advantages such as less co-morbidity and less postoperative pain in comparison with open procedures. Furthermore, the good exposure of the pelvic cavity by laparoscopy and the magnification of anatomical structures seem to facilitate pelvic dissection laparoscopically. Moreover, recent studies describe no difference in safety and oncological radicalness in LCCR compared to the open total mesorectal excision (TME). The oncological adequacy of LCCR still remains unproven today, because long-term results do not yet exist. To date, only a few studies have described the results of laparoscopic TME combined with preoperative adjuvant treatment for colorectal cancer. The aim of this review is to examine the various areas of development and
controversy of LCCR in comparison to the conventional open approach.
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Affiliation(s)
- Beat M Künzli
- Beat M Künzli, Helmut Friess, Department of General Surgery, Technische Universität München, D-81675 Munich, Germany
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Lim YK, Law WL, Liu R, Poon JTC, Fan JFM, Lo OSH. Impact of neoadjuvant treatment on total mesorectal excision for ultra-low rectal cancers. World J Surg Oncol 2010; 8:23. [PMID: 20346160 PMCID: PMC2859360 DOI: 10.1186/1477-7819-8-23] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 03/26/2010] [Indexed: 01/10/2023] Open
Abstract
Background This study reviewed the impact of pre-operative chemoradiotherapy or post-operative chemotherapy and/or radiotherapy on total mesorectal excision (TME) for ultralow rectal cancers that required either low anterior resection with peranal coloanal anastomosis or abdomino-perineal resection (APR). We examined surgical complications, local recurrence and survival. Methods Of the 1270 patients who underwent radical resection for rectal cancer from 1994 till 2007, 180 with tumors within 4 cm with either peranal coloanal anastomosis or APR were analyzed. Patients were compared in groups that had surgery only (Group A), pre-operative chemoradiotherapy (Group B), and post-operative therapy (Group C). Results There were 115 males and the mean age was 65.43 years (range 30-89). APR was performed in 134 patients while 46 had a sphincter-preserving resection with peranal coloanal anastomosis. The mean follow-up period was 52.98 months (range: 0.57 to 178.9). There were 69, 58 and 53 patients in Groups A, B, and C, respectively. Nine patients in Group B could go on to have sphincter-saving rectal resection. The overall peri-operative complication rate was 43.4% in Group A vs. 29.3% in Group B vs. 39.6% in Group C, respectively. The local recurrence rate was significantly lower in Group B (8.6.9% vs. 21.7% in Group A vs. 33.9% in Group C) p < 0.05. The 5-year cancer-specific survival rates for Group A was 49.3%, Group B was 69.9% and Group C was 38.8% (p = 0.14). Conclusion Pre-operative chemoradiation in low rectal cancer is not associated with a higher incidence of peri-operative complications and its benefits may include reduction local recurrence.
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Affiliation(s)
- Yon Kuei Lim
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
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