Brief Article
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World J Gastroenterol. Mar 21, 2013; 19(11): 1797-1804
Published online Mar 21, 2013. doi: 10.3748/wjg.v19.i11.1797
Routine defunctioning stoma after chemoradiation and total mesorectal excision: A single-surgeon experience
Shao-Chieh Lin, Po-Chuan Chen, Chung-Ta Lee, Hong-Ming Tsai, Peng-Chan Lin, Helen HW Chen, Yuan-Hwa Wu, Bo-Wen Lin, Wen-Pin Su, Jenq-Chang Lee
Shao-Chieh Lin, Po-Chuan Chen, Bo-Wen Lin, Jenq-Chang Lee, Division of Colorectal Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
Chung-Ta Lee, Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
Hong-Ming Tsai, Department of Radiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
Peng-Chan Lin, Wen-Pin Su, Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
Helen HW Chen, Yuan-Hwa Wu, Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
Author contributions: Lin SC and Chen PC made equal contributions to the writing of this manuscript; Lee CT, Tsai HM, Lin PC, Chen HHW, Wu YH, Lin BW, Su WP made substantial contributions to study design, data analysis and interpretation; Lee JC originated study conception and made final approval of the version to be published.
Correspondence to: Jenq-Chang Lee, MD, Division of Colorectal Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, East District, Tainan 704, Taiwan. leejc@mail.ncku.edu.tw
Telephone: +886-6-2353535 Fax: +886-6-2250586
Received: November 13, 2012
Revised: December 27, 2012
Accepted: January 23, 2013
Published online: March 21, 2013
Abstract

AIM: To investigate the 10-year results of treating low rectal cancer by a single surgeon in one institution.

METHODS: From Oct 1998 to Feb 2009, we prospectively followed a total of 62 patients with cT2-4 low rectal cancer with lower tumor margins measuring at 3 to 6 cm above the anal verge. All patients received neoadjuvant chemoradiation (CRT) for 6 wk. Among them, 85% of the patients received 225 mg/m2/d 5-fluorouracil using a portable infusion pump. The whole pelvis received a total dose of 45 Gy of irradiation in 25 fractions over 5 wk. The interval from CRT completion to surgical intervention was planned to be approximately 6-8 wk. Total mesorectal excision (TME) and routine defunctioning stoma construction were performed by one surgeon. The distal resection margin, circumferential resection margin, tumor regression grade (TRG) and other parameters were recorded. We used TRG to evaluate the tumor response after neoadjuvant CRT. We evaluated anal function outcomes using the Memorial Sloan-Kettering Cancer Center anal function scores after closure of the defunctioning stoma.

RESULTS: The median distance from the lower margin of rectal cancer to the anal verge was 5 cm: 6 cm in 9 patients, 5 cm in 32 patients, 4 cm in 10 patients, and 3 cm in 11 patients. Before receiving neoadjuvant CRT, 45 patients (72.6%) had a cT3-4 tumor, and 21 (33.9%) patients had a cN1-2 lymph node status. After CRT, 30 patients (48.4%) had a greater than 50% clinical reduction in tumor size. The final pathology reports revealed that 33 patients (53.2%) had a ypT3-4 tumor and 12 (19.4%) patients had ypN1-2 lymph node involvement. All patients completed the entire course of neoadjuvant CRT. Most patients developed only Grade 1-2 toxicities during CRT. Thirteen patients (21%) achieved a pathologic complete response. Few post-operative complications occurred. Nearly 90% of the defunctioning stomas were closed within 6 mo. The local recurrence rate was 3.2%. Pathologic lymph node involvement was the only prognostic factor predicting disease recurrence (36.5% vs 76.5%, P = 0.006). Nearly 90% of patients recovered sphincter function within 2 year after closure of the defunctioning stoma.

CONCLUSION: Neoadjuvant CRT followed by TME, combined with routine defunctioning stoma construction and high-volume surgeon experience, can provide excellent surgical quality and good local disease control.

Keywords: Rectal cancer, Neoadjuvant chemoradiation, Total mesorectal excision, Pathologic complete response, Defunctioning stoma