Neoadjuvant chemoradiation followed by transanal local excision for T2 rectal cancer confers equivalent survival benefit as traditional transabdominal resection

BackgroundDespite clinical guidelines classifying T2 rectal cancer as a contraindication for transanal local excision attributable to unacceptably high rates of local recurrence, it is a practice that persists clinically. Recent clinical trials have suggested that transanal local excision in addition to neoadjuvant chemoradiation is an acceptable alternative in select patients.MethodsThe 2004–2015 National Cancer Database was queried for patients with clinical stage T2N0M0 rectal adenocarcinoma who underwent surgical intervention. Patients were stratified by treatment with transabdominal resection or transanal local excision, both with and without neoadjuvant chemoradiation. Propensity matching was performed, and, using the Kaplan-Meier and Cox proportional hazard models, survival was compared between the groups.ResultsA total of 12,021 patients met inclusion criteria, including 1,761 and 6,629 patients who underwent transabdominal resection with and without neoadjuvant chemoradiation, respectively, and 695 and 2,936 patients who underwent local transanal excision with and without neoadjuvant chemoradiation, respectively. In unadjusted analysis, patients undergoing induction therapy followed by transabdominal resection or local excision had equivalent survival. Similarly, on multivariate Cox proportional hazard regression after propensity matching, local excision was not an independent predictor of patient mortality compared with transabdominal resection (hazard ratio 0.93, 95% confidence interval 0.75–1.16).ConclusionLocal transanal excision in addition to neoadjuvant chemoradiation may provide comparable survival benefit to transabdominal resection for patients with clinical stage T2N0M0 rectal cancer. Therefore, patients who refuse or are poor candidates for transabdominal resection should be considered for neoadjuvant therapy followed by transanal local excision.     

Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation

Background Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation. Methods Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient’s clinical response after chemoradiation and distance from the anal verge. Results A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group. Conclusions The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.     

Results of long-term follow-up for transanal excision for rectal cancer

Low anterior resection and abdominoperineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. It is our hypothesis that selected patients with early T stage, well or moderate grade of differentiation, and small tumor size are good candidates for transanal excision in terms of minimal morbidity, low recurrence rate, and sphincter preservation. From January 1993 until August 2001 30 patients underwent transanal excision; three patients were excluded because they had histology other than adenocarcinoma. Factors analyzed included those related to the patient [age (years), gender, race, body mass index, and anal tone], tumor [size (cm), distance from the anal verge (cm), differentiation, and American Joint Committee on Cancer stage], and additional treatment. Median follow-up of the group was 40.7 months (range 0.6-99) and the primary end points were local and distant recurrence. Data are presented as mean (range). The median age of the group was 58.9 years (range 27-94); 52 per cent were female and 48 per cent were male. The mean body mass index was 25.9 (range 22.7-36.7). Preoperatively 81, 11, and 4 per cent of the patients had stage I, II, and III/IV cancer, respectively. Preoperative size of the tumor was 2.0 cm (1-3 cm), and distance from the anal verge was 5.0 cm (3-15 cm). Blood loss was 50 cm3 (5-200 cm3), and there were no operative complications. Tumor differentiation levels were well (37%) and moderate (63%). All patients had negative margins. Additional treatment consisted of radiation therapy in seven patients (six postoperative and one preoperative). Chemotherapy was given to seven patients (six postoperative and one preoperative). The local recurrence rate was 7.4 per cent (two patients), and 3.7 per cent recurred distantly (one patient). Transanal excision of low rectal cancer in selected patients is an acceptable alternative to formal resection. Important selection criteria include early T stage, well or moderate differentiation, relatively small tumor size, and negative microscopic margins. The roles of radiation and chemotherapy remain controversial.     

腹腔镜辅助经肛全直肠系膜切除手术

男性,50岁,体重质量指数(BMI)26.7 kg/m~2,初始诊断为"低位直肠癌",肿瘤分期为cT_3CN_1M_0;经过术前新辅助放疗后的肿瘤分期为ycT_2N_0M_0,肿瘤下缘距离肛缘的距离为4.5 cm。患者在放疗后6周接受了腹腔镜辅助经肛全直肠系膜切除术,我们采用经腹和经肛两组手术医生团队同时实施手术,经下腹部小切口取出全直肠系膜切除的标本,在腹腔镜辅助下完成消化道重建,并采用荧光腹腔镜吲哚菁绿显像的方法检测吻合口血运。     

经肛门全直肠系膜切除和腹腔镜全直肠系膜切除对直肠癌的疗效对比

目的分析比较经肛门全直肠系膜切除（TaTME）与腹腔镜全直肠系膜切除（LaTME）在中低位直肠癌治疗中的疗效及预后。 方法选择东营市东营区人民医院2015年2月至2016年2月收治的64例择期行全直肠系膜切除术（TME）的中低位直肠癌患者，随机分为TaTME组与LaTME组，各32例。观察并比较两组患者的手术时间、术中出血量、标本完整率、环周切缘（CRM）阳性率、远端切缘（DRM）阴性率、淋巴结清扫数目、保肛率、中转开放手术率、术中及术后并发症、术后住院时间、局部复发率、远处转移率、2年总体生存率（OS）各指标间的差异。 结果TaTME组患者的术中出血量、中转开放手术率、手术时间、标本完整率、CRM阳性率、保肛率、术后住院时间、尿潴留发生率均显著优于LaTME组（均P<0.05）。患者均获随访2~24个月，TaTME组中位生存时间为23.9个月，局部复发率、转移率分别为6.2%（2/32）、3.1%（1/32）。LaTME组中位生存时间为19.7个月，局部复发率、转移率均为3.1%（1/32）。两组术后复发率、转移率比较，差异无统计学意义（χ²=0.350、0.516，P=0.554、0.472）。TaTME组与LaTME组1年OS分别为100.00%、93.75%，2年OS分别为96.87%、81.25%。两组1年OS比较，差异无统计学意义（χ²=0.516，P=0.472），TaTME组的2年OS显著高于LaTME组患者（χ²=4.402，P=0.036）。 结论与LaTME术相比，TaTME术治疗中低位直肠癌具有较高的安全性和有效性，且术后并发症较少，术后住院时间短，可以改善患者预后。     

腹腔镜辅助经肛全直肠系膜切除术与腹腔镜全直肠系膜切除术治疗低位直肠癌的疗效比较

背景与目的：全直肠系膜切除术（TME）是治疗直肠癌的标准术式,与开放TME比较,腹腔镜辅助TME（LaTME）不仅降低了手术创伤,且疗效相当。但对于肥胖、骨盆狭窄、男性低位直肠癌患者,LaTME的盆腔操作仍十分困难,且环周切缘（CRM）阳性的风险增加。腹腔镜辅助经肛TME（TaTME）的出现为低位直肠癌切除术提供了一种创新的微创选择,给外科医生提供新的解决方案。本研究比较分析腹腔镜辅助TaTME与LaTME治疗低位直肠癌的临床疗效。 方法：回顾性分析广东省中医院胃肠外科2018年7月—2019年1月收治的30例低位直肠癌患者（肿瘤下缘距肛门距离≤5 cm）的临床资料。其中12例行腹腔镜辅助TaTME（TaTME组）,18例行LaTME（LaTME组）。比较两组患者的相关临床指标。 结果：两组患者在年龄、性别、BMI、ASA分级、肿瘤学分期、肿瘤下缘距肛门距离、肿瘤直径等一般资料均无明显差异（均P>0.05）。两组患者无中转开腹手术,无近期死亡病例。TaTME组较LaTME组手术时间明显缩短（168.5 min vs. 239.33 min,P=0.007）、出血量明显减少（66.50 mL vs. 160.00 mL,P=0.002）。两组在预防性造口、保肛率、CRM阳性率、淋巴结清扫总数方面差异无统计学意义（均P>0.05）。TaTME组术后住院时间明显短于LaTME组（6.33 d vs. 10.83 d,P<0.001）、住院费用明显低于LaTME组（58 963元 vs. 81 341元,P<0.001）,TaTME组的术后排气时间及恢复全流饮食时间均短于LaTME组,但差异无统计学意义（均P>0.05）。两组术后并发症发生率差异无统计学意义（P>0.05）。  结论：腹腔镜辅助TaTME治疗低位直肠癌与LaTME的短期疗效相当,且在某些方面具有一定优势;是安全可行的,值得临床进一步研究和应用。     

Preoperative chemoradiation and coloanal J pouch reconstruction for low rectal cancer

Our objective was to determine clinical outcomes of treatment of low rectal adenocarcinoma with neoadjuvant chemoradiation, rectal excision, and coloanal J pouch reconstruction. A retrospective review of 69 patients with stage B2 or higher lesions was performed. Preoperative chemoradiation was followed by low anterior resection and coloanal J pouch anastomosis, with end loop ileostomy. Data were analyzed using the SPSS computer software. There were 46 males and 23 females, with a median age of 63 years. Pathologic staging showed no tumor in the specimen, i.e.: stage 0, 14 per cent; stage A, 14 per cent; stage B, 53 per cent; stage C, 18 per cent; and stage D, 1.4 per cent. Postoperative mortality was 2.8 per cent, and the pelvic leak rate was 4.3 per cent. After curative resection, 89 per cent patients are alive and 83 per cent are disease free with a mean follow-up of 50 months. The local recurrence rate is 7.2 per cent. Nodal status was the most important predictor of survival and disease-free survival. Most (96%) have fewer than two bowel movements a day and are satisfied with the functional results. We conclude that preoperative chemoradiation and coloanal J pouch reconstruction can achieve low recurrence rates and prolonged survival for most patients with low rectal cancer with an acceptable quality of life.     

经肛门局部切除手术在直肠癌治疗中的作用

直肠癌的外科手术方法包括经腹根治术及局部切除术。全直肠系膜切除术（TME）是直肠癌外科治疗的金标准．随着功能外科时代的到来．越来越多的证据表明．在严格选择适应证的前提下．早期直肠癌患者行局部切除手术可以获得和传统经腹根治术相同的生存率。但总体而言．局部切除术后的局部复发率要高于TME．因此需要术前做到全面、精确的分期和评估．从而严格掌握局部切除的手术适应证。     

Preoperative therapy for rectal cancer: Short-course radiation vs. long-course chemoradiation

Preoperative radiation therapy for rectal cancer is delivered by two techniques: short-course radiation and long-course chemoradiation. These two approaches cannot be directly compared since patients selected for treatment with short-course radiation commonly included those with cT1–3 disease, whereas chemoradiation is used for cT3 and/or N+ disease. Recent trials of short-course radiation have included patients with cT3 and/or N+ disease as well as delivered sequential or postoperative chemotherapy. This review will evaluate the results of the two preoperative approaches.     

Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery

OBJECTIVE: Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM. MATERIAL AND METHODS: Seventy-nine patients were treated by TEM in the period 1994-2001. The median age was 74 years. The indications for TEM were rectal adenoma in 72 patients and rectal cancer in 7 patients. The tumours were located within 18 cm from the dentate line, median 10 cm. There were performed 69 transmural and 10 mucosal excisions. Mean follow up was 24 months (range 1-95 months). Twenty (25%) patients died during the follow up period, two because of metastases and 18 of other causes. RESULTS: Seven patients had complications. Two (2.5%) patients had peroperative perforation in the intra-abdominal part of the rectum treated by laparotomy. Five (6%) patients had postoperative cardiopulmonal or surgical complications. Eight patients with benign pre-operative histopathological examination had cancer. The local recurrence rate (13%) was similar for adenomas and for carcinomas. CONCLUSION: TEM is a safe technique well tolerated also by high-risk patients, and should be the preferred method in patients with benign tumours in the middle and upper part of the rectum, and in selected cases of early rectal cancer. Benign pre-operative histology does not preclude malignancy and some patients may need further treatment for unexpected malignancy.     

Plasma Fatty Acid Composition in Continuous Ambulatory Peritoneal Dialysis Patients: An Increased Omega-6/Omega-3 Ratio and Deficiency of Essential Fatty Acids

Abstract

Patients with end-stage renal disease, including those treated with peritoneal dialysis, have a high risk for death, particularly from cardiovascular causes. Plasma fatty acid (FA) composition is used as an indicator of disease risk, because its alteration has been related to metabolic disease and cardiovascular disease. For this purpose, we have measured plasma FA composition in continuous ambulatory peritoneal dialysis (CAPD) patients and compared them with those of healthy subjects. This study was performed on 51 (21 M, 30 F) CAPD patients at least 6 months under dialysis, aged 20–75 years (mean 47.81 ± 11.8 years) and 45 (25 M, 20 F) healthy control subjects aged 20–60 years (mean 38.62 ± 12.9 years). Plasma 10-cis-pentadecanoic acid, 10-cis-heptadecanoic acid, heneicosanoic acid, tricosanoic acid, nervonic acid, saturated fatty acid, and monounsaturated FA levels and delta 9 desaturase activity were significantly higher whereas linoleic acid, linolenic acid, 11,14-eicosedienoic acid, arachidonic acid, docosahexaenoic acid, and omega-3 FA levels were significantly lower in the CAPD group than those in the healthy group. Our results show that there are FA abnormalities and especially a depletion in essential FA levels and a high level of omega-6/omega-3 ratio in CAPD patients, the underlying mechanism of which is not known and needs to be investigated. Therefore, we believe that essential FA supplementation should be encouraged for CAPD patients.     

Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer: Two distinct principles

Extended pelvic lymphadenectomy (EPL) with total mesorectal excision (TME) has been reported to provide oncological benefit in lower rectal cancer in Japan. In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation (CRT) followed by TME has been established as a standard treatment for decreasing local recurrence. Recently, several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan. A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone. Considering that almost 45% survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes (LLNs), EPL performed by experienced surgeons definitely contributes to decrease local recurrence. On the other hand, a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT. On this point, preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs. For future treatment, it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis. Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups, further studies would lead to the next great step towards future improvement in treating lower rectal cancer.     

低位直肠癌术前辅助放疗与全系膜切除术

直肠癌在我国呈上升趋势,在结直肠癌的统计中,直肠癌的发生率占结直肠癌总数的70%[1]。在这些病例中,中低位直肠癌也占较高的比例。特别是我国的直肠癌患者,进展期所占比例较高,术前的辅助治疗显得十分重要。美国NCCN公布的直肠癌治疗指南中明确规定了直肠癌术前辅助放化疗是可选择的重要治疗方法。这对我国直肠癌的治疗有着积极的指导作用。全直肠系膜切除术(total mesorectal excision,TME)已在欧洲确定为直肠癌治疗的标准术式,TME的技术也趋于成熟。在我国外科医师已经接受了TME的概念并在努力实施这种手术。直肠癌的术前辅助放化…