Risk Factors and Oncologic Impact of Anastomotic Leakage after Rectal Cancer Surgery

Purpose  The impact of anastomotic leakage on the long-term oncologic outcome is not clear. This retrospective study evaluated risk factors and oncologic impacts of anastomotic leakage after rectal cancer surgery. Methods  Data were analyzed from 1,391 patients who underwent sphincter preservation for rectal cancer between January 1997 and August 2003. Operations were classified as anterior resection (n = 164), low anterior resection (n = 898), or ultralow anterior resection (n = 329). Results  The anastomotic leakage rate was 2.5 percent. Multivariate analysis identified male (hazard ratio, 3.03), old age (hazard ratio, 2.42), and lower anastomosis level (hazard ratio, 2.68) as risk factors for leakage. The local recurrence rates were 9.6 and 2.2 percent for the leakage and nonleakage groups, respectively but were not significant (P = 0.14). The overall five-year survival rates were 55.1 and 74.1 percent in the leakage and nonleakage groups, respectively (P < 0.05), and the cancer-specific survival rates were 63 and 78.3 percent in the leakage and nonleakage groups, respectively (P = 0.05). However, in subgroup analysis, significant differences were identified only in Stage III patients. Conclusions  Age, sex, and ultralow anterior resection were found to be risk factors for anastomotic leakage after rectal cancer surgery. In addition, leakage was associated with poor survival. Poster presentation at the meeting of The American Society Colon and Rectal Surgeons, Seattle Washington, June 3 to 7, 2006.     

Long-term outcome of anastomosis leakage after curative resection for mid and low rectal cancer

BACKGROUND/AIMS: The aim of this study was to evaluate the relationship of the disease recurrence and prognosis of rectal cancer with anastomosis leakage after curative low anterior resection. METHODOLOGY: The records of 566 patients with primary rectal adenocarcinoma in the Veterans General Hospital-Taipei, Taiwan between 1991 and 1997 were reviewed. Patients who did not have anastomosis (abdominoperineal resection 72, Hartmann's operation 15), did not have curative resection (62) or expired within 30 days after operation (11) were excluded from the study. Another 34 patients were excluded because they did not visit our clinic or could not be reached by telephone or questionnaire after operation. 372 patients who received restorative curative resection with a colorectal anastomosis were analyzed. The product-limit method (Kaplan-Meier) and Cox proportional hazard model were used to analyze survival rate and tumor recurrence. RESULTS: Twenty-five out of the 406 patients had anastomosis leakage after the operation. The 5-year disease-free, local recurrence-free survival of the leakage group (32.5%, 58.7%) was significantly lower than that of the non-leakage group (71%, 88.3%). The multivariate analysis showed TNM staging (p = 0.0001) and histological differentiation (p = 0.0002) were associated with overall tumor recurrence. The factors affected local tumor recurrence were TNM staging (p = 0.006) and anastomosis leakage (p = 0.014). CONCLUSIONS: These results suggested that anastomotic leakage after curative rectal surgery is associated with the local tumor recurrence-free survival rate even after adjusting for stage.     

Prognosis After Anastomotic Leakage in Colorectal Surgery

INTRODUCTION Anastomotic leakage is a major complication of colorectal surgery causing a significant increase in 30-day mortality. The long-term prognosis of anastomotic leakage is poorly documented. This study was designed to assess whether anastomotic leakage affects five-year survival and local recurrence.METHODS A total of 5,173 patients were recruited to the Wessex Colorectal Cancer Audit during the period September 1991 to August 1995 (prospective data, 5-year follow-up). The effect of anastomotic leakage on five-year survival and local recurrence was analyzed using Kaplan-Meier curves and the log-rank test.RESULTS A total of 1,834 patients underwent a curative resection with an anastomosis (anastomotic leak = 71; 3.9 percent): 30-day mortality: 18.3 percent in the leak group, and 3.5 percent in the nonleak group (P < 0.001); local recurrence: 19 percent in the leak group, and 9.8 percent in the nonleak group (P = 0.018). A total of 1,201 patients underwent colonic anastomosis (anastomotic leak = 31; 2.6 percent). There was no significant difference in local recurrence or five-year survival between the leak and nonleak groups. A total of 633 patients underwent rectal anastomosis (anastomotic leakage = 40; 6.3 percent): 30-day mortality: 10 percent in the leak group, and 2 percent in the nonleak group (P = 0.014); cumulative five-year estimate of local recurrence: 25.1 (95 percent confidence interval, 9.6–40.5) percent in the leak group, and 10.4 (95 percent confidence interval, 7.7–13) percent in the nonleak group (P = 0.007). Cumulative five-year estimate of overall survival: 52.8 (95 percent confidence interval, 36.1–69.4) percent in the leak group, and 63.9 (95 percent confidence interval, 59.9–67.9) percent in the nonleak group (P = 0.19).CONCLUSIONS After rectal anastomosis, an anastomotic leak is associated with a significant increase in local recurrence.Reprints are not available.Supported by Ethicon Endo-Surgery, which enabled this data to be presented to the European Association of Coloproctology, Sitges, Barcelona, Spain, September 18 to 20, 2003.     

Clinicopathological features of colorectal cancer in patients over 70 years of age

Abstract

Objective. The aim was to identify the clinical factors and tumor characteristics that predict mortality and survival in patients older than 70 years with colorectal adenocarcinoma. Material and methods . One hundred and ninety-four patients with colorectal cancer aged over 70 years were identified from a computer database and their clinical variables were analyzed by both univariate and multivariate analyses. Results. All patients underwent resective surgery, 79% radical and 21% palliative resection, and postoperative mortality was 6% being associated with the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 38%, the median survival 35 months, and the cancer-specific 5-year survival 48% and this did not differ significantly between the age groups. The recurrence rate after radical surgery was 30%, being 12, 22, 56, and 100% in Dukes classes A, B, C, and D. Kaplan-Meier estimates indicated that gender, Dukes staging, grade of tumor, number of lymph node metastasis, venous invasion, and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion and recurrent disease were independent prognostic factors of survival. Conclusions. Low mortality and acceptable survival can be achieved in elderly patients with colorectal cancer. Venous invasion and recurrent cancer are independent predictors of survival.     

The value of omentoplasty in protecting colorectal anastomosis from leakage. A prospective randomized study in 126 patients

BACKGROUND/AIMS: Anastomotic leakage is a major cause of mortality in colorectal surgery. Several methods have been evaluated in order to prevent anastomotic leakage. To decrease the rate and severity of anastomotic leakage, omentoplasty (OP) has been proposed by several authors on the basis of experimental and clinical studies. A prospective, randomized trial was designed to study the influence of omentoplasty on anastomotic leakage after colorectal resection. METHODOLOGY: One hundred and twenty-six patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and other were randomly assigned to omentoplasty (OP group) or not (NO group). The primary end point was the rate of clinical and radiological anastomotic leakage. Both groups were comparable in terms of demographic data, preoperative characteristics and intraoperative findings. RESULTS: Eighteen patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Significant differences (P<0.05) between the two groups were also found in terms of repeat operation (3.2% vs. 14.1%) and deaths (3.2 vs. 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. CONCLUSIONS: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of anastomotic leakage after colorectal surgery.     

Risk Factors of Anastomotic Leakage and Long-Term Survival After Colorectal Surgery

Anastomotic leakage (AL) is one of the most serious complications of colorectal surgery. It can affect long-term oncologic outcomes, but the impact on long-term survival remains uncertain. The aim of this study is to evaluate the operative characteristics of leakage and no leakage groups and to analyze long-term oncologic outcomes.We prospectively enrolled 10,477 patients from 2000 to 2011 and retrospectively reviewed the data.Male sex (odds ratio [OR], 3.90; P < 0.001), intraoperative transfusion (OR, 2.31; P = 0.042), and operative time (OR, 1.73; P = 0.032) were independent risk factors of AL in the colon. In the rectum, male sex (OR, 2.37; P < 0.001), neoadjuvant chemoradiotherapy (OR, 2.26; P < 0.001), and regional lymph node metastasis (OR, 1.43; P = 0.012) were independent risk factors of AL, and diverting stoma (OR, 0.24; P < 0.001) was associated with a deceased risk of AL. AL in the rectum without a diverting stoma was associated with disease-free survival (DFS, OR, 1.47; P = 0.037). Colonic leakage was not associated with 5-year DFS (leakage group vs nonleakage group, 72.4% vs 80.9%, P = 0.084); however, in patients undergoing rectal resection, there was a significant difference in 5-year DFS (67.0% vs 76.6%, P = 0.005, respectively).AL in the rectum is associated with worse long-term DFS and overall survival. A diverting stoma was shown to protect against this effect and was associated with long-term survival in rectal surgery. Therefore, creating a diverting stoma should be considered in high-risk patients undergoing rectal surgery.     

Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction

Background and aims Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage. Materials and methods Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3–4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively. Results/findings No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023). Interpretation/conclusion Patient’s safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.     

Transanal extirpation for early rectal cancer

Transanal extirpation was performed in 38 patients with adenocarcinoma of the rectum. In 17 patients (group I) the tumor extended into the submucosa only, and in 14 patients (group II) tumors extended into, but not through, the muscularis propria. There was a significant difference in local recurrence between groups I and II. None of the patients in group I and six of the patients (42.6 percent) in group II developed local recurrences (P=0.02). The 5-year actuarial survival probability was 100 and 82.6 percent, respectively. Transanal extirpation is an alternative to transsphincteric and abdominoperineal resection in the treatment of early well or moderately well-differentiated cancer of the rectum. The surgical procedure is simple and has few complications; however, only tumors extending no deeper than the submucosa are suitable for this treatment. The operation should be followed by frequent sigmoidoscopies and rectal palpation. The procedure should be defined as an excisional biopsy until results from the histologic examination are presented.     

Comparison of salvage chemoradiation versus salvage surgery for recurrent esophageal squamous cell carcinoma after definitive radiochemotherapy or radiotherapy alone

A consensus treatment strategy for esophageal squamous cell carcinoma (ESCC) patients who recur after definitive radiochemotherapy/radiotherapy has not been established. This study compared the outcomes in ESCC patients who underwent salvage surgery, salvage chemoradiation (CRT) or best supportive care (BSC) for local recurrence. Ninety‐five patients with clinical stage I to III ESCC who had completely responded to the initial definitive radiochemotherapy or radiotherapy alone and developed local recurrence were enrolled in this study. Fifty‐one of them received salvage esophagectomy, and R0 resection was performed in 41 patients, 36 underwent salvage CRT, and the remaining eight patients received BSC only. The 5‐year overall survival was 4.6% for the 87 patients receiving salvage surgery or CRT, while all patients in the BSC group died within 12.0 months, the difference was statistically significant (P = 0.018). The 1‐, 3‐, 5‐year survival rates in the salvage surgery and salvage CRT groups were 45.1%, 20.0%, 6.9% and 51.7%, 12.2%, 3.1%, respectively, there was no difference of overall survival between the two groups (P = 0.697). Patients also presented with lymph node relapse had inferior survival compared to those with isolated local tumor recurrence after salvage therapy. In the salvage surgery group, infections occurred in eight patients, and three developed anastomotic leakage. In the salvage CRT group, grade 2–4 esophagitis and radiation pneumonitis was observed in 19 and 3 patients, respectively. Seven patients (19.4%) developed esophagotracheal fistula or esophageal perforation. This study of salvage CRT versus salvage surgery for recurrent ESCC after definitive radiochemotherapy or radiotherapy alone did not demonstrate a statistically significant survival difference, but the frequency of complications including esophagotracheal fistula and esophageal perforation following salvage CRT was high.     

Multicenter Analysis of Long-Term Oncologic Impact of Anastomotic Leakage After Laparoscopic Total Mesorectal Excision: The Korean Laparoscopic Colorectal Surgery Study Group

This study aims to validate the oncologic outcomes of anastomotic leakage (AL) after laparoscopic total mesorectal excision (TME) in a large multicenter cohort.The impact of AL after laparoscopic TME for rectal cancer surgery has not yet been clearly described.This was a multicenter retrospective study of 1083 patients who underwent laparoscopic TME for nonmetastatic rectal cancer (stage 0–III). AL was defined as an anastomotic complication within 30 days of surgery irrespective of requiring a reoperation or interventional radiology. Estimated local recurrence (LR), disease-free survival (DFS), and overall survival (OS) were compared between the leakage group and the no leakage group using the log-rank method. Multivariate Cox-regression analysis was used to adjust confounding for survival.The incidence of AL was 6.4%. Mortality within 30 days of surgery occurred in 1 patient (1.4%) in the leakage group and 2 patients (0.2%) in the no leakage group. The leakage group showed a higher LR rate (6.4% vs 1.8%, P = 0.011). Five-year DFS and OS were significantly lower in the leakage group than the no leakage group (DFS 71.7% vs 82.1%, P = 0.016, OS 81.8% vs 93.5%, P = 0.007). Multivariate analysis showed that AL was an independent poor prognostic factor for DFS and OS (hazard ratio [HR] = 1.6; 95% confidence intervals [CI]: 1.0–2.6; P = 0.042, HR = 2.1; 95% CI: 1.0–4.2; P = 0.028, respectively).AL after laparoscopic TME was significantly associated with an increased rate of LR, systemic recurrence and poor OS.     

Prospective Comparison of Laparoscopic vs. Open Resections for Colorectal Adenocarcinoma Over a Ten-Year Period

PURPOSE: The aim of this study was to define the long-term oncologic outcomes of laparoscopic resections for colorectal cancer. METHODS: We analyzed our experience via a prospective, nonrandomized, longitudinal cohort study. The period of study extended from April 1991 to May 2001. Laparoscopic resection was offered selectively in the absence of a large mass, invasion into abdominal wall or adjacent organs, and multiple prior abdominal operations. Every laparoscopic resection performed with curative intent for adenocarcinoma was included. Twenty percent of patients whose procedures were converted to open resection were included in the laparoscopic-resection group because of intention to treat. Oncologic outcome measures of this group were compared with a computerized, case-matched, open-resection group, the case-matching variables being age, gender, site of primary tumor (colon vs. rectum), and TNM stage. The laparoscopic-resection group was followed up prospectively, and data were updated regularly. The follow-up techniques consisted of a combination of office visits, telephone calls, and the United States Social Security Death Index database. RESULTS: The laparoscopic-resection group consisted of 172 patients with a mean age of 67 (range, 27–85) years. The open-resection group consisted of 172 patients with a mean age of 69 (range, 30–90) years. Mean follow-up was 52 (range, 3–128) months. Complete (100 percent) follow-up data were available. The TNM stage distribution was 63 Stage I (37 percent), 51 Stage II (30 percent), 47 Stage III (27 percent), and 11 Stage IV (6 percent) tumors for the laparoscopic-resection group and 65 Stage I (38 percent), 48 Stage II (28 percent), 51 Stage III (29 percent), and 8 Stage IV (5 percent) tumors for patients in the open-resection group (P = 0.75, not significant). Thirty-day mortality was 1.2 percent (2 deaths) in the laparoscopic-resection group and 2.4 percent (4 deaths) in the open-resection group (P > 0.05, not significant). Early and late complication incidences were comparable. Local recurrence was observed in three patients (1.7 percent) in the laparoscopic resection group with the primary tumor in the colon and in three patients (1.7 percent) with the primary tumor in the rectum, for a total incidence of local recurrence in the laparoscopy group of 3.5 percent (6 patients). In the open-resection group, local recurrence was observed in two patients (1.2 percent) among those with primary tumor site in the colon and in three patients (1.7 percent) in the group with primary tumor in the rectum, for a total incidence of local recurrence in the open-resection group of 2.9 percent (5 patients). One of the local recurrences in the laparoscopy group occurred in the port/extraction site, for an incidence of 0.6 percent. Metastasis occurred in 18 patients (10.5 percent) in the open group and in 21 (12.2 percent) in the laparoscopy group. Stage-for-stage overall five-year survival rates were similar in the two groups. The Kaplan-Meier statistical analysis performed for colonic vs. rectal primary adenocarcinoma confirmed that TNM stage for stage-overall survival was similar in the laparoscopic and open-resection groups (log-rank P = 0.22). CONCLUSIONS: Notwithstanding the drawbacks of a nonrandomized study, no adverse long-term oncologic outcomes of laparoscopic resections for colorectal cancer were observed in a single centers experience during a ten-year period.     

Stratifying risk factors for follow-up

INTRODUCTION: The selection of patients for individualized follow-up and adjuvant therapy after curative resection of colorectal carcinoma depends on finding reliable prognostic criteria for recurrence. However, such criteria are not universally accepted, and follow-up is often standardized for all patients without regard for each individual's level of risk of recurrence. Such a system of follow-up is not cost-effective. METHODS: A comparison of operative findings, pathologic features, and follow-up data of 1,731 cases of nonrecurrent colorectal cancer (821 colon, 910 rectum) with 357 cases of recurrent colorectal cancer (164 colon, 193 rectum) following potentially curative surgery was made, and results were analyzed to ascertain criteria for stratifying follow-up according to risk factors. RESULTS: Single-factor analysis showed that Dukes staging and tumor invasion were significantly associated with recurrence in both rectal and colon carcinoma. Tumor fixation and grading were additional significant factors in rectal cancer. Recurrence rates, time to recurrence, site of recurrence (locoregionalvs. distant), and pattern of metastatic spread were not significantly affected by original tumor site. Recurrence was not significantly affected by patient age and gender. Individual surgeon performance in this series had also no significant effects on tumor recurrence. With multivariate analysis only, Dukes staging and tumor invasion into adjacent tissues were found to be independent adverse prognostic factors for recurrence. CONCLUSIONS: Dukes staging and tumor penetration into adjacent tissues are the only significant adverse prognostic factors for tumor recurrence of colonic and rectal carcinoma. Tumor grade and tumor fixation are additional adverse prognostic factors in rectal cancer. Guidelines for follow-up may be based on these factors and follow-up thus stratified according to risk of developing recurrence.     

The prognostic utility of the histologic subtype of stage I lung adenocarcinoma may be diminished when using only the invasive component to determine tumor size for tumor node metastasis (TNM) staging

BackgroundHistologic subtypes were considered prognostic factors in early-stage lung adenocarcinoma in the 7^th edition of the tumor node metastasis (TNM) staging system (TNM-7). However, the T-staging system has changed and now measures only the size of the invasive component to determine tumor size. The aim of this study was to determine whether the histologic subtype is still a prognostic factor in the 8^th edition of the TNM staging system (TNM-8).MethodsFrom 2010 to 2017, 788 patients who underwent curative surgery for stage I lung adenocarcinoma according to TNM-8 were analyzed retrospectively. Survival rates were compared among predominant patterns of adenocarcinoma. Prognostic factors were analyzed according to risk factors for recurrence in stage I lung adenocarcinoma.ResultsThe 5-year recurrence-free survival rates among predominant histologic subtypes were statistically different, especially between the lepidic/acinar/papillary group and the micropapillary/solid group. Total tumor size was not significantly different between the two groups, but invasive component size was different (1.5 vs. 2.3 cm, P<0.001). In the multivariate analysis that adopted total tumor size as a variable, visceral pleural invasion (VPI), lymphovascular invasion (LVI), and micropapillary-predominant adenocarcinoma were significant predictors for recurrence. Conversely, adenocarcinoma subtypes were not significant risk factors for recurrence in the multivariate analysis that adopted invasive component size as a variable.ConclusionsThe importance of adenocarcinoma subtype for prognosis may be reduced when only the invasive component of a tumor is used to determine tumor size, as described in the TNM-8 staging system.     

High preoperative serum carcinoembryonic antigen predicts metastatic recurrence in potentially curative colonic cancer: Results of a five-year study

INTRODUCTION: Serum carcinoembryonic antigen is used mainly for tumor follow-up to detect recurrence of colonic cancer. However, raised preoperative carcinoembryonic antigen levels may be helpful for the identification of understaged cases and of patients meriting more intensive preoperative and postoperative diagnostic workup. METHODS: From a prospectively collected database, the data on 261 patients who had curative colonic carcinoma with a minimal follow-up of five years and who had preoperative carcinoembryonic antigen levels assessed were retrieved and analyzed. Outcome parameters were local and/or distant recurrence and time to recurrence. These parameters were correlated with Dukes staging and preoperative carcinoembryonic antigen levels. RESULTS: The cumulative diseasefree survival of patients with a preoperative carcinoembryonic antigen level within the normal range was significantly better than that of those whose carcinoembryonic antigen was 5 ng/ml or more (P=0.001). No patient with carcinoembryonic antigen levels less than 1 ng/ml developed metastatic recurrence. Twenty-three percent of all patients with a raised carcinoembryonic antigen above 5 ng/ml compared with 2.1 percent of patients with carcinoembryonic antigen below 5 ng/ml developed a metastasis at two years. At five years, these figures were 37.2 percent and 7.5 percent, respectively. Dukes staging and carcinoembryonic antigen levels were found to be directly correlated (P<0.001) when all patients were included. Carcinoembryonic antigen of more of 15 ng/ml was found to be a significant adverse prognostic indicator for disease-free survival irrespective of Dukes staging (P<0.02). Raised carcinoembryonic antigen levels predicted distant metastatic recurrence (P<0.001) but did not predict local recurrence (P=0.72). CONCLUSIONS: High preoperative carcinoembryonic antigen levels above 15 ng/ml predicted an increased risk of metastatic recurrence in potentially curative colonic cancer and may indicate undetectable disseminated disease. Preoperative carcinoembryonic antigen levels predict understaging and the possibility of distant recurrence. Such patients may therefore be selected for adjuvant therapy where indicated. Therefore, carcinoembryonic antigen is complementary to conventional Dukes staging for the prediction of recurrence and survival.     

Patterns of recurrence following high-dose preoperative radiation and sphincter-preserving surgery for cancer of the rectum

High-dose preoperative radiation with new sphincter-preserving surgical options for the management of distal and unfavorable cancers of the rectum is gaining recognition as an alternative to abdominoperineal resection and permanent colostomy. From 1976 to 1989, 161 patients with cancer of the rectum were entered into a program of high-dose preoperative radiation and radical sphincter-preserving surgery. Selection was based on prospective clinical staging of unfavorability or tumor location at a low level in the rectum. All patients received a minimum dose of 4,000 to 4,500 cGy over 4 1/2 weeks in fractional doses of 180 to 250 cGy. Patients with tumor fixation were given an additional boost of 1,000 to 1,500 cGy for a total of 5,500 to 6,000 cGy using a coned-down field. Surgery was carried out four to eight weeks following completion of radiation. Fourteen patients, found at surgery to have liver metastasis, were treated by palliative resection. One hundred forty-seven patients underwent radical curative surgery with sphincter preservation. The surgical procedures performed were combined abdominotranssacral resection (63), transanal-abdominal-transanal resection (53), and anterior resection (31). Follow-up ranged from a minimum of two years to 15 years, with a median of five years. There was no perioperative mortality. Anastomotic failure occurred in three patients, two of whom were reconstituted. Late diversion was required in 10 other patients, primarily for recurrent disease. One hundred thirty-four of the 147 patients (91 percent) maintained long-term normal sphincter function. Pelvic-perineal recurrence was observed in 18 patients (12.4 percent), 12 of whom had fixed tumors located below the 6-cm level of the distal rectum. Median time to local recurrence was 24 months. Distant metastasis with or without local recurrence occurred in 35 patients, 22 of whom had fixed tumors below the 6-cm level of the rectum. Median time to distant metastasis was 17 months. Forty-three patients have died, 32 of disease. The overall five-year Kaplan-Meier actuarial survival for the total group of patients is 79 percent, with a disease-free survival of 73 percent. The findings of this study indicate that high-dose preoperative radiation used in combination with radical sphincter-preserving surgical techniques results in excellent local control of disease, improved survival, and enhanced quality of life with retention of normal anal sphincter function.     

Outcomes for Abdominoperineal Resections Are Not Worse Than Those of Anterior Resections

Purpose Local recurrence and cure rates following abdominoperineal resections have been reported to be much worse than sphincter-preserving anterior resections. We compared the oncologic outcomes of patients treated by abdominoperineal resections with those following sphincter-preserving anterior resections. Methods The medical records of patients who underwent radical rectal resection for rectal carcinoma at the Colorectal Surgery Department, Singapore General Hospital, during the period from April 1989 to April 2002 were reviewed. A total of 791 cases were studied. Operative procedures were classified as either abdominoperineal resections or anterior resections with either straight or pouch anastomosis. Total mesorectal excision was routinely performed for carcinomas of the lower middle and lower third of the rectum. Sentinel events, including local and systemic recurrences or morbidity and mortality, were tracked prospectively. Results There were a total of 93 abdominoperineal resections (12.1 percent), 547 anterior resections with straight anastomoses (71 percent), and 130 anterior resections with pouch anastomoses (16.9 percent). Postoperative mortality was 2.6 percent and postoperative morbidity was 13.6 percent with an overall anastomotic leakage rate of 2.5 percent. The cumulative five-year local recurrence rate was 5.4 percent for abdominoperineal resections, 3.6 percent for anterior resections with straight anastomoses, and 3.8 percent for anterior resections with pouch anastomoses (P = 0.73 by log-rank test). The median time to local recurrence also did not differ significantly between the different procedures (abdominoperineal resections, 17 months, anterior resections with straight anastomoses, 18 months, anterior resections with pouch anastomoses, 13 months). Independent predictors for local recurrence included advanced tumor stage, tumor depth, and poorly differentiated tumors. The five-year cancer-specific survival was 70 percent. The type of anastomosis did not influence disease-free survival with median disease-free survival for patients who underwent abdominoperineal resections being 100 months, survival of anterior resections with straight anastomoses being 135 months, and survival of anterior resections with pouch anastomoses being 121 months (P = 0.33 by log-rank test). The independent factors for poor survival were age greater than 65 years, advanced tumor stage, tumor depth, and poorly differentiated tumors. Conclusion Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections. Reprints are not available.     

Seminal vesicle-rectal fistula

A previously unreported complication of low anterior resection of the rectum, seminal vesicle-rectal fistula, was encountered one month after surgery in an elderly patients with adenocarcinoma of the midrectum. Antibiotic-induced colitis in the immediate postoperative period led to anastomotic leakage with abscess formation and ensuing fistulization to the surgically denuded right seminal vesicle. Pneumaturia, bacteriuria, and right testicular pain were treated by cutaneous vasostomy and antimicrobial therapy. Despite recurrent low-grade urinary sepsis controlled by alternating courses of various antimicrobials, and radiation therapy for local tumor recurrence, the patient remained reasonably healthy until his death two years later due to stroke associated with cerebral metastases.     

Evaluation of Prognosis for Malignant Rectal Gastrointestinal Stromal Tumor by Clinical Parameters and Immunohistochemical Staining

PURPOSE The aim of this study was to identify associated prognostic factors influencing the outcome of curative resection of rectal gastrointestinal stromal tumor.PATIENTS AND METHODS Diagnostic immunohistochemical staining with CD34, CD117, S-100, desmin, and muscle-specific actin was performed in 46 consecutive patients with previously diagnosed rectal leiomyosarcoma who underwent curative resection from 1979 to 1999. CD44, Bcl-2, P53, and Ki-67 staining were performed on tumors rediagnosed as gastrointestinal stromal tumor for the prognostic evaluation.RESULTS There were 42 (91.3 percent) patients with rectal gastrointestinal stromal tumor (18 females and 24 males; mean age, 58.4 years). Twenty-nine patients underwent radical surgical resections, such as abdominoperineal resection or low anterior resection, whereas the other 13 patients underwent wide local excision, such as transrectal excision or Kraskes operation. Sixteen tumors were classified as high-grade gastrointestinal stromal tumors, and 26 as low-grade. No tumor had a positive P53 stain. Twenty-seven patients (64.3 percent) developed recurrence or metastasis postoperatively (median follow-up, 52 months). The one-year, two-year, and five-year disease-free survival rates were 90.2 percent, 76.7 percent, and 43.9 percent, respectively. Of these patients with recurrence, subsequent resections in 12 patients with local recurrence, transarterial tumor embolism or STI-571 chemotherapies in 3 patients with distant mestastases were performed. The one-year, two-year, and five-year overall survival rates were 97.4 percent, 94.3 percent, and 83.7 percent, respectively. Bcl-2 (P = 0.007) and histologic grade (P = 0.05) in disease-free survival analysis and age <50 years (P = 0.03) and tumor size >5 cm (P = 0.02) in overall survival analysis were independent prognostic factors. The group with wide local excision had a higher local recurrence rate than that of the radical resection group (77 percent vs. 31 percent, P = 0.006), despite smaller tumors (4.5 vs. 7.2 cm, P = 0.05). There was no difference in the incidence of distant metastasis between the two groups.CONCLUSION Younger age (<50 years), higher histologic tumor grade, positive Bcl-2 status, and larger tumors (>5 cm) were factors associated with significantly poorer prognoses for rectal gastrointestinal stromal tumor. Radical resection was superior to wide local excision in the prevention of local recurrence, but not that of distant metastases.     

Routine Mobilization of the Splenic Flexure is not Necessary During Anterior Resection for Rectal Cancer

Purpose Splenic flexure mobilization is widely considered to be an essential component of anterior resection for rectal cancer. It was our hypothesis that selective splenic flexure mobilization would reduce operative times without increasing morbidity or affecting cure. Methods A total of 100 consecutive patients with rectal cancer (mean 8 (range, 4–15) cm from anal verge) who underwent anterior resection for cure between 1996 and 2002 had splenic flexure mobilization only as required to achieve a tension-free anastomosis. Operative time, postoperative morbidity, pathologic findings, and recurrence rates were recorded. Results There were no clinicopathologic differences between those who had splenic flexure mobilization (n = 26) and those who did not (n = 74). Mean operative time in the splenic flexure mobilization group was longer, 167 (range, 130–200) minutes vs. 120 (range, 95–180) minutes in the nonmobilized group (P = 0.023). Mean length of specimen resected was longer in the splenic flexure mobilization group: 36 vs. 18 cm (P = 0.008). Anastomotic complications (4 percent), local recurrence (7 percent, median follow-up, 38 months), perioperative morbidity (32 percent) and mortality (2 percent), and survival did not differ between the two groups. Conclusions Routine splenic flexure mobilization is not required for safe anterior resection in patients with rectal cancer. Avoiding splenic flexure mobilization results in shorter operative times and does not increase postoperative morbidity, anastomotic leakage, or local recurrence. Presented at the Freyer Surgical Meeting, Galway, Ireland, September 2 to 3, 2005.     

Intraoperative radiation therapy for curatively resected rectal cancer

PURPOSE: Intraoperative radiotherapy has been used for local control of locally advanced rectal cancer. The aim of this study was to investigate the efficacy of intraoperative radiotherapy for curatively resected rectal cancer. METHODS: Between 1982 and 1998, intraoperative radiotherapy was administered in combination with curative resection in 78 patients with adenocarcinoma of the middle or lower third of the rectum (intraoperative radiotherapy group). Sixty-two of the patients had received preoperative radiotherapy with 20 Gy. Intraoperative radiotherapy was performed by a new strategy in which an electron beam was administered as uniformly as possible to the entire dissected surface of the pelvis. Retrospective comparisons were made with 248 patients treated by surgery alone during the same period (non-intraoperative radiotherapy group). RESULTS: The differences in tumor stage or surgical procedures between the two groups were not statistically significant. Survival, disease-free survival, and local recurrence-free survival in the intraoperative radiotherapy group were significantly more favorable than in the non-intraoperative radiotherapy group (P=0.01,P=0.04, andP=0.02). Differences in survival were observed in Stage II patients but not in Stage I or Stage III patients. The local failure rate was 2.6 percent in the intraoperative radiotherapy group and 11.3 percent in the non-intraoperative radiotherapy group, and the difference was significant (P=0.02). The distant metastasis rate was 18.0 percent in the intraoperative radiotherapy group and 19.5 percent in the non-intraoperative radiotherapy group, and the difference was not significant. There was a significantly higher rate of wound infection in the intraoperative radiotherapy group, but no infections were serious. CONCLUSIONS: In patients with adenocarcinoma of the middle or lower third of the rectum, intraoperative radiotherapy to the entire dissected surface of the pelvis reduced local recurrence in Stage II and Stage III patients and improved survival in Stage II patients.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.