Salvage radical surgery after failed local excision for early rectal cancer

OBJECTIVES: Local recurrence after transanal excision of rectal cancer is often amenable to salvage radical proctectomy, but the long-term results remain unknown. This study was designed to determine the outcome of salvage radical surgery after failed local excision in patients with early rectal cancer. METHODS: We retrospectively reviewed the charts of 29 patients who underwent salvage radical surgery for local recurrence after a full-thickness transanal excision for Stage I rectal cancer. End points included local and distant recurrences and disease-free survival after salvage radical surgery. Comparisons between groups were performed by chi-squared test. RESULTS: Recurrence involved the rectal wall in 26 patients (90 percent) and was purely extrarectal in only 3 (10 percent). Mean time between local excision and radical operation was 26 months. The resection was considered curative in 23 patients (79 percent). The stage of the recurrent tumor was more advanced than the primary tumor in 27 patients (93 percent). At a mean follow-up of 39 (range, 2-147) months after radical surgery, 17 patients (59 percent) remained free of disease. The disease-free survival rate was 68 percent for patients with tumors with favorable histology vs. 29 percent for patients with tumors with unfavorable histology. CONCLUSION: Salvage surgery for recurrence after local excision of rectal cancers may not provide results equivalent to those of initial radical treatment. In the present study the poor results of salvage surgery emphasize the importance of appropriate selection of the initial treatment of Stage I rectal cancer.     

Locally recurrent rectal cancer

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio Texas, May 2 to 7, 1998.     

Surgical treatment of low-lying carcinoma of the rectum

The standard operative treatment of low-lying rectal cancer has been abdominoperineal resection. In the elderly patient, this treatment has significant risk. One-fourth of the patients had major complications and another one-fourth had minor complications. The operative mortality was 6.8 per cent for patients 65 years of age and over and 7.7 per cent for patients 70 years old and over. Patients with metastatic disease at the time of diagnosis had a dismal prognosis despite treatment with abdominoperineal resection. Postoperative pelvic radiotherapy should help reduce pelvic recurrence. Generally, patients with tumors less than 5 cm in diameter and less than 5 cm from the dentate line should be considered for initial transanal excision. It appears that very good local tumor control can be achieved by transanal excision for tumors confined to the bowel wall. Only 6.9 per cent of patients with tumors confined to the bowel wall had lymph node metastasis. The low risk of occult lymph node metastasis from tumors confined to the bowel wall is offset by the operative risk of abdominoperineal resection. Further evaluation of transanal excision of selected rectal cancers is indicated. Patients with villous adenomas with superficial carcinoma can be adequately treated repetitively with transanal local excision. In this case, there was a 50 per cent local recurrence rate. Local recurrence occurred in some patients five or more years after the initial treatment, thus emphasizing the need for prolonged close proctoscopic follow-up.     

A comparison of transanal excision and endoscopic resection for early rectal cancer

AIM: To compare the outcomes of endoscopic resection with transanal excision in patients with early rectal cancer.METHODS: Thirty-two patients with early rectal cancer were treated by transanal excision or endoscopic resection between May 1999 and December 2007. The patients were regularly re-examined by means of colonoscopy and abdominal computed tomography after resection of the early rectal cancer. Complications, length of hospital-stay, disease recurrence and follow up outcomes were assessed.RESULTS: Sixteen patients were treated by endoscopic resection and 16 patients were treated by transanal excision. No significant differences were present in the baseline characteristics. The rate of complete resection in the endoscopic resection group was 93.8%, compared to 87.5% in the transanal excision group (P = 0.544). The mean length of hospital-stay in the endoscopic resection group was 2.7 ± 1.1 d, compared to 8.9 ± 2.7 d in the transanal excision group (P = 0.001). The median follow up was 15.0 mo (range 6-99). During the follow up period, there was no case of recurrent disease in either group.CONCLUSION: Endoscopic resection was a safe and effective method for the treatment of early rectal cancers and its outcomes were comparable to those of transanal excision procedures.     

Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

PURPOSE Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.METHODS All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.RESULTS Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39–43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2–90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.CONCLUSIONS Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 7, 2002.     

Transanal Excision vs. Major Surgery for T1 Rectal Cancer

PURPOSE The purpose of this national study was to examine the long-term results of transanal excision compared with major surgery of T1 rectal cancer.METHODS This prospective study from the Norwegian Rectal Cancer Project included all 291 patients with a T1M0 tumor within 15 cm from the anal verge treated by anterior resection, abdominoperineal resection, Hartmann’s procedure, or transanal excision in the period from November 1993 to December 1999.RESULTS Two hundred fifty-six patients were treated by major surgery and 35 patients by transanal excision. None of the patients had neoadjuvant therapy. Macroscopic tumor remnants (R2) occurred in 17 percent (6/35) of the transanal excisions, while major surgery obtained 100 percent R0 resections. Eleven percent of the patients treated with major surgery had glandular involvement. There were no significant differences according to tumor localization, size, or differentiation between Stage I and Stage III tumors. Patients treated with transanal excision were older than patients having major surgery (mean age, 77 vs. 68 years, P < 0.001). After curative resection (R0, R1, Rx) the five-year rate of local recurrence was 12 percent (95 percent confidence interval, 0–24) in the transanal excision group compared with 6 percent (95 percent confidence interval, 2–10) after major surgery (P = 0.010). The overall five-year survival was 70 percent (95 percent confidence interval, 52–88) in the transanal excision group compared with 80 percent (95 percent confidence interval, 74–85) in the major surgery group (P = 0.04) and the five-year disease-free survival was 64 percent (95 percent confidence interval, 46–82) in the transanal excision group compared with 77 percent (95 percent confidence interval, 71–83) in the major surgery group (P = 0.01).CONCLUSIONS The main problem of transanal excision for early rectal cancer in the present study was the inability to remove all the malignancy. Patients treated with transanal excision had significantly higher rates of local recurrence compared with patients who underwent major surgery. Patients who had transanal excision had inferior survival, but they were older than those who had major surgery.From the Norwegian Gastrointestinal Cancer Group and the Norwegian Rectal Cancer Group.This work was supported by a grant from the Norwegian Cancer Society.Presented at the XXth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Budapest, Hungary, June 6 to 10, 2004.     

Local excision carcinoma in early stage

AIM: To assess the validity of local excision for the early stage low rectal cancer as an effective treatment alternative to radical resection. METHODS: A retrospective medical chart review was done in 47 patients with early stage low rectal carcinoma who underwent local excision from November 1980 through November 1999 at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS). The patients were treated by either transanal (40 cases), trans-sacral (5 cases), or trans-vaginal (2 cases) excision of tumors and no death was related to surgery. Sixteen patients received postoperative radiotherapy. RESULTS: T1 and T2 lesion was found in 36 (76.6 %) and 11 patients (23.4 %) respectively. The overall local tumor recurrence rate was 14.9 % (7/47), with an average recurrence time of 21 months. Among these 7 recurrent patients, there were 4 T1 and 3 T2 lesions. Microscopically, the surgical incisal margin was negative in 45 (95.7 %) and positive in 2 patients (4.3 %); Both of the later had developed local recurrence. The overall 5-year survival rate was 91.7 %, in which there were 94.4 % for T1 and 83.3 % for T2 tumors. T stage, intravessel tumor thrombosis, lymphocytic infiltration and histological grade were not found to be significant by related to the local recurrence and survival (P>0.05). CONCLUSION: Local tumor excision was a safe procedure for the treatment of early stage low rectal carcinoma with minimal morbidity and mortality, which might serves as one of the primary surgical treatment methods for the disease of this kind.     

A prospective analysis of patient outcome following treatment of T3 rectal cancer with neo-adjuvant chemoradiotherapy and transanal excision

Background

Local excision is an alternative to anterior or abdomino-perineal resection in patients with early rectal cancer. In more advanced disease, neo-adjuvant therapy (CRXT) can result in significant disease regression such that local excision may be considered. The primary aim was to assess oncological outcome in patients with T3 rectal cancer treated with CRXT and local excision due to unsuitability for or aversion to anterior resection and stoma. The secondary aim was to examine oncological outcomes in patients treated in a similar way in the published literature.

Methods

Between July 2006 and July 2009, patients with rectal cancer staged T3, N0/N1, M0 who were deemed unfit for or who refused anterior resection were offered long-course CRXT. Patients were restaged 8 weeks following completion. If there was a good response (regression grade 2 or 3 clinically and radiologically), full thickness transanal excision was performed. All patients were followed regularly (monthly CT abdomen/pelvis and annual endoscopy) to assess for recurrence of disease. A literature search of PubMed was performed to identify all prospective data available of T3 rectal cancers managed with CRXT and local excision.

Results

Ten patients were treated over 3 years. Six patients had complete pathological response, while four patients had a partial response. The resection margins following local excision were clear in all. There was no local recurrence (median follow-up 24 months, range 9–42 months).

Conclusion

Neo-adjuvant chemoradiotherapy and local excision is an option in patients unfit for or averse to major surgical resection if there is a good response to CRXT.

     

Is local excision adequate therapy for early rectal cancer?

PURPOSE: Radical surgery of rectal cancer is associated with significant morbidity, and some patients with low-lying lesions must accept a permanent colostomy. Several studies have suggested satisfactory tumor control after local excision of early rectal cancer. The purpose of this study was to compare recurrence and survival rates after treating early rectal cancers with local excision and radical surgery. METHODS: One hundred eight patients with T1 and T2 rectal adenocarcinomas treated by transanal excision were compared with 153 patients with T1N0 and T2N0 rectal adenocarcinomas treated with radical surgery. Neither group received adjuvant chemoradiation. Mean follow-up time was 4.4 years after local excision and 4.8 years after radical surgery. RESULTS: The estimated five-year local recurrence rate was 28 percent (18 percent for T1 tumors and 47 percent for T2 tumors) after local excision and 4 percent (none for T1 tumors and 6 percent for T2 tumors) after radical surgery. Overall recurrence was also higher after local excision (21 percent for T1 tumors and 47 percent for T2 tumors) than after radical surgery (9 percent for T1 tumors and 16 percent for T2 tumors). Twenty-four of 27 patients with recurrence after local excision underwent salvage surgery. The estimated five-year overall survival rate was 69 percent after local excision (72 percent for T1 tumors and 65 percent after T2 tumors) and 82 percent after radical surgery (80 percent for T1 tumors and 81 percent for T2 tumors). Differences in survival rate between local excision and radical surgery were statistically significant in patients with T2 tumors. CONCLUSIONS: Local excision of early rectal cancer carries a high risk of local recurrence. Salvage surgery is possible in most patients with local recurrence, but may be effective only in patients with T1 tumors. When compared with radical surgery, local excision may compromise overall survival in patients with T2 rectal cancers.Supported by Minnesota Colon and Rectal Foundation and TUMORS database.Read at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Early rectal cancer: definition and management

BACKGROUND: Local excision of rectal cancer is an alternative to radical resection but today its role surrounding the management of patients with early stage rectal cancer (T1-T2-N0) represents an important surgical issue. AIM: To analyze the results of 135 patients with early stage low rectal cancer treated with local excision by transanal endoscopic microsurgery and in the case of T2 also by neoadjuvant therapy. STUDY DESIGN: 135 patients with T1-T2-N0-M0 rectal cancer were enrolled in the study. Staging according to the definitive histological findings was as follows: pT0 in 24 patients (17.8%), pT1 in 66 patients (48.8%) and pT2 in 45 patients (33.4%). RESULTS: Minor complications were observed in 12 patients (8.8%) whereas major complications were seen only in 2 patients (1.5%). At a median follow-up of 78 (36-125) months, local recurrences occurred in 4 patients and distal metastasis in 2 patients (all patients were staged preoperatively T2). Disease-free survival rates in T1 and T2 patients were 100 and 93% respectively at the end of follow-up. CONCLUSIONS: With respect to local recurrence and survival rate, the long-term results of early stage rectal cancer in patients treated with transanal endoscopic microsurgery were similar to those reported in the literature after conventional surgery (total mesorectal excision).     

Usefulness of local excision for early lower rectal cancer

BACKGROUND/AIMS: The purpose of this study was to examine the long-term results of transanal excision compared with major surgery for lower rectal cancer. METHODOLOGY: This retrospective study included 14 patients with early rectal cancer within 8cm from the anal verge treated by local excision in the period from January 1991 to December 2000, and 16 patients treated by major surgery in the period from January 1996 to December 2000. We evaluated the prognosis or anorectal or urinary function of these patients. RESULTS: Six of the patients had additional treatments which included additional resection or adju vant chemotherapy. None of these patients had macroscopic tumor remnants (R2). With the exception of one patient who died of heart disease, all of the patients survived without metastasis. Anorectal and urinary function maintained a good status. CONCLUSIONS: Local excision for early rectal cancer (Tis N0 M0) brought an excellent outcome, and maintained good anorectal and urinary function. We recommend local excision for the early rectal cancer patients.     

Outcome of Transanal Endoscopic Microsurgery and Adjuvant Radiotherapy in Patients with T2 Rectal Cancer

Purpose The use of transanal endoscopic microsurgery for local excision of rectal cancer has recently gained wide acceptance as a valid and safe alternative for the surgical treatment of T1 tumors. The adequacy of such treatment for T2 tumors, however, is still controversial. This study was designed to evaluate our results with local excision of T2 cancers. Methods Patients with T2 cancer admitted to our hospital between 1995 and 2005 were offered surgery by transanal endoscopic microsurgery if found medically unfit or were unwilling to undergo radical surgery. Patients who were preoperatively staged as T1 tumor but were found to be pathologically T2 also were included. Results Overall, we performed 59 transanal endoscopic microsurgery operations for rectal cancers, of which 21 were for T2 cancers. In 16 (76 percent) of the T2 patients, the tumors were completely removed with clear margins by transanal endoscopic microsurgery and no additional surgery was performed, except for 2 patients who developed radiation-induced complications. Radical surgery was performed in a second operation in five patients because of involved margins and residual disease was found in two. At a median follow-up of three years, all 12 patients who received local excision and radiotherapy remained disease free, whereas a 50 percent recurrence rate was observed in patients who refused adjuvant radiotherapy. Conclusions The results of this study support the feasibility of transanal endoscopic microsurgery for the treatment of selected patients with T2 rectal cancer. The addition of radiotherapy may decrease the rates of early local recurrence. However, at present, this treatment strategy should not be routinely considered for patients who may undergo radical procedures.     

Evaluation of local excision for sessile-type lower rectal tumors.

BACKGROUND/AIMS: A study was undertaken to evaluate the surgical morbidity and risk of recurrence in patients undergoing local excision for rectal carcinoma. METHODOLOGY: Twenty patients with well or moderately differentiated lesions less than 6 cm in diameter, which were difficult to remove endoscopically but had no clinically involved regional nodes, were eligible for local excision. RESULTS: The transanal approach was simple and had few complications. After posterior parasacral excision, 3 patients developed rectocutaneous fistulas, and 1 of them died. None of the 12 patients with cancer extension limited to the lesser depth of the submucosa died of rectal cancer. Among 8 patients with cancer invasive into the greater depth of the submucosa or deeper, 5 underwent additional radical resection, and regional lymph node metastasis was revealed in 2. CONCLUSIONS: Transanal excision is suitable for curative resection of lower rectal tumors when the cancer extends only to the lesser depth of the submucosa. The procedure should be defined as a total excisional biopsy until the results of histologic examination are obtained.     

Transanal Endoscopic Microsurgical Resection of pT1 Rectal Tumors

Purpose Transanal endoscopic microsurgery has emerged as an improved method of transanal excision of neoplasms because its enhanced visibility, superior optics, and longer reach permit a more complete excision and precise closure. This study will show that transanal endoscopic microsurgical treatment of pT1 rectal cancers is safe and achieves low local recurrence and high survival rates. Methods Retrospective review performed of all pT1 rectal cancers treated by a single surgeon (TS) using transanal endoscopic microsurgery between 1991 and 2003. Patient age, gender, tumor distance from the anal verge, lesion size, operative time, blood loss, complications, recurrence, and survival rates were prospectively recorded. Results Fifty-three patients (average age, 65.6 (range, 31–89) years) were studied. Forty-nine percent were male. Average tumor distance from the anal verge was 7 (range, 0–13) cm; average size was 2.4 (range, 1–10) cm. Radiation and/or chemotherapy were not administered. Sixteen patients had pT1 lesions removed piecemeal during colonoscopy; there was no residual tumor after transanal endoscopic microsurgical resection of the polyp site. Mean follow-up was 2.84 years. Fifty-one percent had longer than two-year follow-up. For the entire group, there were four recurrences (7.5 percent) occurring at 9 months, 15 months, 16 months, and 11 years. Two were treated with abdominoperineal resection, one with low anterior resection, and one with fulguration alone. There were no recurrences in the 16 patients who had excision of the polypectomy site. If excluded, recurrence was 11 percent (4/37). Patients were examined at three-month intervals for the first two years and every six months thereafter. There have been no cancer-related deaths. Conclusions Transanal endoscopic microsurgical resection of pT1 rectal cancers yields low recurrence rates. Close follow-up permits curative salvage for those that do recur. Transanal excision remains a viable option. Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. Reprints are not available.     

Significance of lateral node dissection for advanced rectal carcinoma at or below the peritoneal reflection

Two hundred thirty two patients with rectal cancer at or below the peritoneal reflection, who underwent extended systematic lymphadenectomy, especially lateral node dissection, were reviewed with respect to survival rate, degree of surgical technique, and mode of recurrence. On the basis of the extent of lateral node spread, two types of lateral node dissection were performed, consisting of preservation of internal iliac vessels (conventional) anden bloc excision of these vessels (extended). The overall disease-free five-year survival rate was 69.4 percent in all patients—75.8 percent for those who underwent extended resection and 67.4 percent for those who underwent conventional resection an excellent survival rate of 49 percent of patients with lateral node metastasis was obtained. The analysis was carried out with regard to prognostic factors such as number of node metastases, obesity index, mode of recurrence, etc. We would recommend that systemic lymphadenectomy with lateral node dissection be performed for advanced rectal cancer at or below the peritoneal reflection.     

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994–2003

Background and aims This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution.Patients and methods One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures.Results The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5–100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006).Conclusion With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.     

Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure

BACKGROUND: Transanal intersphincteric resection (ISR) was introduced and has been increasingly performed as an ultimate surgical treatment for extremely low rectal cancer. We considered that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined. METHODS: Between December 2003 and June 2004, we performed laparoscope-assisted ISR for two patients with very low rectal cancer and total colectomy for two patients with ulcerative colitis complicated by colorectal cancer. In all patients, the transanal procedure was preceded by trans-abdominal laparoscopic rectal excision. RESULTS: Preceding transanal dissection facilitated muscle layer-oriented curative dissection, and more importantly, made subsequent laparoscopic rectal excision effortless as a result of penetrating to the dissected pelvic cavity. All patients showed favorable recovery including postoperative anal function with no complication or recurrent disease. CONCLUSIONS: This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease, while preserving anal function.     

Surgery for Locally Recurrent Rectal Cancer

PURPOSE Resection of locally recurrent rectal cancer after curative resection represents a difficult clinical problem and a surgical challenge. The aim of this study was to assess the outcome of a series of patients who underwent resection of locally recurrent rectal cancer with curative intent.METHODS A retrospective review was performed of 64 patients who underwent surgical exploration with a view to cure for locally recurrent rectal cancer under the care of one surgeon between April 1997 and April 2004. Details were obtained on the primary tumor and the operation, the indication for investigation of recurrence, preoperative imaging, operative findings, morbidity and mortality, and histopathology.RESULTS The median time interval between resection of primary tumor and surgery for locally recurrent disease was 31 (interquartile range, 21 to 48) months. Twenty-three patients had central disease, 10 patients had sacral involvement, 21 patients had pelvic sidewall involvement, and 10 patients had both sacral and sidewall involvement. Fifty-seven patients underwent resection of the tumor. Thirty-nine of the 57 patients underwent wide resection (abdominoperineal excision of rectum, anterior resection, or Hartmanns procedure) whereas 18 patients (31.6 percent) required radical resection (pelvic exenteration or sacrectomy). Curative, negative resection margins were obtained in 21 of 57 patients who had tumor excision (36.8 percent). Perioperative mortality was 1.6 percent. Significant postoperative morbidity occurred in 40 percent of patients.CONCLUSIONS This study has shown that a significant proportion of patients with locally recurrent rectal cancer can undergo resection with negative margins.     

The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review

Techniques in Coloproctology - The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin...     

Abdominoperineal Excision With Partial Anterior En Bloc Resection in Multimodal Management of Low Rectal Cancer: A Strategy to Reduce Local Recurrence

Purpose Total mesorectal excision is the gold standard inthe performance of an abdominoperineal resection but little has changed in the way the perineal operation is performed. A frequent problem is anterior dissection. The aim of this study was to present the results of abdominoperineal resection using selected partial anterior en bloc resection to reduce recurrence. Methods The data were population-based and prospectively registered. Two experienced surgeons performed the operations. In selected cases, depending on clinical and magnetic resonance imaging findings, parts of the vagina or prostate close to the tumor were resected. All specimens were examined according to Quirke. Results Sixty-three patients underwent abdominoperineal resection with total mesorectal excision; 56 received preoperative radiotherapy. The tumors involved the anterior bowel wall in 40 cases and in 23 (58 percent) of them, en bloc resections were performed. The distance from the tumor to the conventional resection margin (without en bloc resection) was 0 mm in ten cases. The median follow-up period was 37 months. So far, one (1.7 percent) local recurrence has been detected in 58 (92 percent) curative and indeterminate cases. The cancer-specific five-year survival in these cases was 87 percent (Kaplan-Meier). Conclusion A multimodal management regimen in patients with low rectal cancer, including preoperative radiotherapy and abdominoperineal resection with a high frequency of partial en bloc resection of the vagina or prostate, resulted in excellent local control and survival. In some male patients, excenteration with urinary stoma can be avoided. Presented at the meeting of the European Association of ColoProctology (EACP), Geneva, Switzerland, September 16 to 18, 2004. Supported by a research grant from the County of V?stmanland, Sweden. Reprints are not available.