Local recurrence following surgical treatment for carcinoma of the lower rectum

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).     

The functional results of radical rectal cancer surgery: review of the literature

Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME.

Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria.

Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called “low anterior resection syndrome” (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation.

Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.     

Quality of mesorectum after laparoscopic resection for rectal cancer - Results of an audited teaching programme in Spain

Objective  The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer.
Method  In April 2006, the Spanish Association of Surgeons started an audited teaching programme. The project was similar to the Norwegian one and several training courses were arranged. Patients were classified into two groups: laparoscopic rectal resection (LR) and open rectal resection (OR). The quality of the mesorectum was scored: complete, nearly complete or incomplete. The circumferential margin (CRM) was considered positive, if tumour was located 1 mm or less from the surface of the specimen.
Results  Between 2006 and 2008, 604 patients underwent rectal resection with total mesorectal excision for rectal cancer: 209 patients were included in the LR group and 395 patients in the OR group. There were no differences in terms of number of lymph nodes affected, distance of the tumour from CRM. The mesorectum was complete in 464 (76.8%), nearly complete in 91 (15.1%) and incomplete in 49 patients (8.1%). CRM was negative in 534 patients (88.4%). No differences were observed between the two groups. The overall postoperative morbidity rate was 38.8% in LR group and 44.6% in OR group ( P  = 0.170). Overall postoperative mortality rate was 2.5%. One patient died (0.5%) in the LR group and 14 patients died (3.5%) in the OR group ( P  = 0.021).
Conclusion  Laparoscopic resection for rectal cancer is feasible with the quality of mesorectal excision and postoperative outcomes similar to those of open surgery.     

腹腔镜下全直肠系膜切除治疗低位直肠癌的体会

【摘要】〓目的〓总结腹腔镜下全直肠系膜切除治疗低位直肠癌的手术体会。方法〓选择我院2007年3月至2012年6月收治的低位直肠癌患者,根据手术方法不同,选择腹腔镜下全直肠系膜切除术50例(腹腔镜组)和开腹下实施直肠癌全直肠系膜切除术50例(开腹组),对两组病人术中出血量、手术时间、术后肛门排气时间、住院时间、切除淋巴结总数、住院总费用、随访结果等资料进行对比及临床分析。 结果〓腹腔镜组术中出血量、手术时间、术后肛门排气时间、住院时间均较开腹组少(P均<0.05);术中淋巴结清扫、直肠远切端距癌灶最下缘距离与开腹组没有明显差异(P>0.05);腔镜组的术后并发症及术后复发均较开腹组少(P<0.05)。结论〓腹腔镜下全直肠系膜切除治疗低位直肠癌与开腹组相比,腹腔镜组在减少损伤及术后恢复方面优于开腹组。而且腹腹镜组术后复发率低于开腹组。     

腹腔镜全直肠系膜切除治疗低位直肠癌(附198例临床资料报告)

目的探讨腹腔镜全直肠系膜切除治疗低位直肠癌的可行性和安全性。方法回顾分析198例腹腔镜全直肠系膜切除治疗低位直肠癌病例资料。结果全组无手术死亡,无中转开腹。平均手术时间（211.5&#177;69.2）min,中位出血量80（50～200）mL,平均切除淋巴结数为（11.5&#177;6.4）枚,平均肛门排气时间（2.8&#177;1.4）d,平均可下地行走时间（1.6&#177;0.9）d,平均术后住院时间（11.8&#177;6.4）d。术后并发症发生率为20.71%,最常见为肠梗阻（占并发症的24.4%）。中位随访时间为26.1（13.6～45.2）个月,随访率86.9%。33例出现术后复发转移,其中吻合口复发2例,盆腔局部复发3例,腹腔广泛转移4例,远处转移24例。死亡共37例,其中死于肿瘤相关因素28例,死于非肿瘤相关因素9例。5例带瘤生存。结论腹腔镜全直肠系膜切除治疗低位直肠癌不仅具有疼痛轻、恢复快等优点,在技术上也是安全可行的,而最终的结果仍有待于大量的、长期的前瞻性随机对照研究。     

腹腔镜辅助中低位直肠癌手术治疗的体会

目的：探讨腹腔镜辅助治疗中低位直肠癌的安全性与可行性。方法：回顾分析76例中低位直肠癌患者腹腔镜手术的临床资料。结果：73例成功施行了腹腔镜手术,保肛率84.9%（62/73）,局部复发率0.06%（5/73）,均至少保留了一侧盆腔自主神经,无严重并发症发生。结论：遵循全直肠系膜切除（total mesorectal excision,TME）原则施行保留自主神经的腹腔镜手术可提高疗效及保肛率。     

腹腔镜全直肠系膜联合经肛门内括约肌切除治疗低位直肠癌的疗效探讨

目的探讨腹腔镜全直肠系膜（TME）联合经肛门内括约肌切除（ISR）治疗低位直肠癌的疗效,评估手术的安全性。方法回顾性分析2009年1月至2012年12月采用腹腔镜TME联合ISR术治疗的42例低位直肠肿瘤患者（腹腔镜组）,同时选取2006年1月至2012年12月开腹行TME联合ISR术治疗的44例低位直肠肿瘤患者（开腹组）。比较分析两组患者的一般资料、手术情况、临床病理特点、术后并发症和术后生活质量。结果两组患者的一般情况和术后临床病理特点相近。腹腔镜组患者均顺利完成手术,总体手术时间（min）明显小于开腹组（181.2±65.4 vs 216.6±82.9,t=2.192,P=0.031）,出血量（ml）亦明显小于开腹组（83.2±37.5 vs 117.4±33.0,t=4.495,P〈0.01）。4例低位直肠癌患者发生吻合口瘘,经保守治疗治愈,并发症发生率与开腹组相比差异无统计学意义。两组患者肛门功能自我评价以及KIRWAN分级差异均无统计学意义。结论对于术前评估早中期低位甚至超低位直肠癌,特别是肿瘤没有侵犯肛门内括约肌的患者,采用腹腔镜TME联合ISR术是安全可行的,提高了保肛成功率,保留患者术后肛门括约肌功能,改善生活质量。     

腹腔镜经腹会阴联合手术治疗低位直肠癌的临床体会

目的:探讨腹腔镜经腹会阴联合手术治疗低位直肠癌的临床疗效及操作体会。方法:回顾分析为31例低位直肠癌患者行腹腔镜经腹会阴联合手术的临床资料,手术均采用五孔法,操作过程中遵循"以神经为核心,沿间隙解剖"及恶性肿瘤的根治原则。结果:31例均顺利完成腹腔镜手术,术中出血量平均(48.77±17.87)ml,手术时间平均(189.84±43.26)min,术后胃肠功能恢复时间平均(49.29±12.54)h,术后平均住院(8.55±1.12)d,清扫淋巴结总数平均(22.58±5.33)枚。均无血管、输尿管损伤发生,患者康复出院,无排尿及性功能障碍。结论:掌握淋巴结的清扫、输尿管及神经的保护,注意盆底创面的浆膜化,注重术后功能的恢复等相关手术细节,腹腔镜经腹会阴联合手术治疗低位直肠癌是安全、可靠的。术中应遵循"以神经为核心,沿间隙解剖"及恶性肿瘤的根治原则,注重外科层面的游离、血管切断、神经输尿管的保护及造口的处理等。     

腹腔镜与开腹低位直肠癌根治术的疗效对比

目的 评估腹腔镜手术治疗低位直肠癌的临床应用价值、疗效以及安全性.方法 回顾性分析2006年10月至2012年10月在上海市嘉定区中心医院行低位直肠癌根治术的患者143例,根据手术方式分为腹腔镜组(69例)和开腹组(74例),比较两组围手术期及术后生存率情况.结果 腹腔镜组和开腹组在年龄、性别、病理类型、肿瘤分化、肿瘤分期等方面差异均无统计学意义(P＞0.05);腹腔镜组手术时间(171.4±63.6 min)大于开腹组(146.1±47.1 min),术中出血量(63.4±23.6 mLvs.92.6±31.8 mL)、术后排气时间(2.5±1.3 d vs.3.6±1.1d)、术后留置导尿管时间(4.6±1.9 d vs.6.3±2.2d)腹腔镜组均小于开腹组,腹腔镜组术后总并发症的发生率与开腹组相似(7.0％ vs 13.2％)(P＞0.05),术后吻合口漏率、肺部感染、切口感染、泌尿系感染两组差异无统计学意义;术后随访时间12～60个月,中位随访时间54个月,腹腔镜组和开腹组在术后1年、3年、5年的生存率、无瘤生存率和局部复发率等方面差异均无统计学意义(P＞0.05).结论 腹腔镜手术治疗低位直肠癌是安全可行的,其远期疗效和开腹手术相似,在对盆腔神经丛的保护和对低位直肠癌的保肛方面可能更有优势,值得推广.     

腹会阴联合切除与经肛提肌外腹会阴切除术治疗低位直肠癌的近期疗效比较

目的探讨经肛提肌外腹会阴切除术(ElAPE)治疗进展期低位直肠癌的可行性、安全性及有效性。方法回顾分析33例进展期低位直肠癌患者的临床资料,其中采用ELAPE手术18例,传统腹会阴联合切除术(APR)15例。结果两组患者年龄、性别、肿瘤分期、肿瘤位置、手术时间、术后并发症发生率比较差异无统计学意义(P0.05),ElAPE组与APR组患者术中失血.量、术后标本环周切缘阳性率及肠管穿孔率比较差异有统计学意义(P0.05)。结论进展期低位直肠癌行ELAPE手术安全可行,可减少术中出血,降低术中标本穿孔率及标本环周切缘阳性率,且未增加并发症发生率。     

Quality of surgery for rectal carcinoma: comparison between open and laparoscopic approaches

Background

Macroscopic evaluation of a tumor specimen is an independent prognostic factor of oncologic outcome after total mesorectal excision (TME) for rectal cancer. This study aimed to assess macroscopic quality of specimens acquired after laparoscopic versus open TME in patients with low rectal cancer.

Patients and methods

Seventy-two patients with low rectal cancer underwent TME either by open (n = 39) or laparoscopic (n = 33) approach. In all specimens, the cut edge of the peritoneal reflection at the anterior mid-rectum, the Denonvillier's fascia, the visceral fascia covering the mesorectum both posteriorly and laterally, and the bowel wall below the mesorectum were macroscopically assessed.

Results

Colorectal anastomoses were located significantly lower in the laparoscopic than in the open group (P < .001). The Denonvillier's fascia was violated in 7 patients after open surgery (P = .01). A significantly more complete TME with intact visceral pelvic fascia was performed after laparoscopy compared with open surgery (P = .025).

Conclusions

Laparoscopy offers a macroscopically more complete specimen after TME for rectal cancer than the open approach because it offers a better view in the pelvis.     

Circumferential margin plays an independent impact on the outcome of rectal cancer patients receiving curative total mesorectal excision

Background

The aim of this study was to determine the impact of the circumferential resection margin on the outcomes of patients with rectal cancer undergoing total mesorectal excision.

Methods

Medical records from July 2004 to June 2008 were prospectively reviewed, and 348 patients who underwent potentially curative surgery for rectal cancer were identified. The influence of the circumferential resection margin on local recurrence, distant metastasis, and 5-year cancer-specific survival was assessed.

Results

Of 348 patients, 13 (3.7%) had positive circumferential resection margins. During a median follow-up period of 58.0 months, 8 patients (2.3%) had local recurrence and 53 (15.2%) developed distant metastases. Local recurrence rates and distant metastasis rates in patients with positive circumferential resection margins were 15.4% and 61.5%, respectively, significantly higher than in those with negative circumferential resection margins (1.8% and 13.4%, respectively) (P < .001). The 5-year cancer-specific survival rates were 75.8% and 0% for patients with tumors having negative and positive circumferential resection margins, respectively (P < .001).

Conclusions

A circumferential resection margin of ≤1 mm adversely affects cancer-specific survival, local recurrence, and distant metastasis.     

直肠癌根治性前切除后复发转移的危险因素

目的 研究直肠癌根治性前切除后复发转移的危险因素。方法 回顾性分析1983—2000年间单个医疗机构直肠癌根治性前切除的957例患者的临床资料，分析复发转移的危险因素。结果 共计有150例患者（15．7％）复发转移，复发转移部位依次为盆腔内局部复发57例（6．0％）、肝脏转移47例（4．9％）、肺部转移40例（4．2％）和其他部位转移6例（0．6％），中位复发转移时间18个月（2—85个月）。复发转移后中位生存8个月（1—62个月）。23例患者（15．3％）切除了肿瘤，术后中位生存30个月，生存超过5年者只有3例（13．0％）。低龄（P=0．024）、有肿瘤家族史（P=0．000）、癌胚抗原（CEA）水平（P=0．003）、肿瘤浸透肌层（P=0．000）、淋巴结转移（P=0．000）、脉管瘤栓（P=0．000）、印戒细胞癌或黏液腺癌（P=0．000）显著增加复发转移的风险。Logistic回归分析发现，肿瘤家族史（P=0．001）、CEA阻性（P=0．033）、肿瘤浸透肌层（P=0．000）、淋巴结转移（P=0．000）、脉管瘤栓（P=0．001）、印戒细胞癌或者黏液腺癌（P=0．012）是有显著统计学意义的复发转移的危险因素。结论 直肠癌根治性前切除后存在特定的复发转移危险因素。盆腔、肝脏和肺是肿瘤复发转移的主要部位。