Robotic rectal surgery: State of the art

Laparoscopic rectal surgery has demonstrated its superiority over the open approach, however it still has some technical limitations that lead to the development of robotic platforms. Nevertheless the literature on this topic is rapidly expanding there is still no consensus about benefits of robotic rectal cancer surgery over the laparoscopic one. For this reason a review of all the literature examining robotic surgery for rectal cancer was performed. Two reviewers independently conducted a search of electronic databases (PubMed and EMBASE) using the key words “rectum”, “rectal”, “cancer”, “laparoscopy”, “robot”. After the initial screen of 266 articles, 43 papers were selected for review. A total of 3013 patients were included in the review. The most commonly performed intervention was low anterior resection (1450 patients, 48.1%), followed by anterior resections (997 patients, 33%), ultra-low anterior resections (393 patients, 13%) and abdominoperineal resections (173 patients, 5.7%). Robotic rectal surgery seems to offer potential advantages especially in low anterior resections with lower conversions rates and better preservation of the autonomic function. Quality of mesorectum and status of and circumferential resection margins are similar to those obtained with conventional laparoscopy even if robotic rectal surgery is undoubtedly associated with longer operative times. This review demonstrated that robotic rectal surgery is both safe and feasible but there is no evidence of its superiority over laparoscopy in terms of postoperative, clinical outcomes and incidence of complications. In conclusion robotic rectal surgery seems to overcome some of technical limitations of conventional laparoscopic surgery especially for tumors requiring low and ultra-low anterior resections but this technical improvement seems not to provide, until now, any significant clinical advantages to the patients.     

低位直肠癌经肛提肌外腹会阴联合切除术的研究进展

目的 肛提肌外腹会阴联合切除术(exralevator abdominoperineal excision,ELAPE)的提出旨在改善低位直肠癌的手术安全性和肿瘤预后,但其应用仍存在争议.本研究总结ELAPE治疗低位直肠癌的最新研究进展.方法 应用PubMed及CNKI期刊全文数据库检索系统,以"肛提肌外、腹会阴联合切除术和低位直肠癌"为关键词,检索2006-01-2015-12的相关文献.纳入标准:(1)ELAPE的疗效分析;(2)ELAPE术后并发症的处理;(3)ELAPE的适用范围;(4)ELAPE体位的选择.排除标准:(1)综述和会议汇编等相关文献;(2)实验设计不严谨.根据纳入和排除标准,符合分析53篇,其中英文文献45篇,中文文献8篇.结果手术是低位直肠癌的首选治疗方案,ELAPE作为治疗低位直肠癌新的术式,目前其手术体位,术后盆底重建,手术疗效及适用范围等方面存在诸多争议,仍需要进一步探讨,尤其是手术疗效及患者术后生活质量亟需进一步的前瞻性研究来验证.结论ELAPE尚不能取代传统腹会阴联合切除术(abdominoperinealexcision,APE)而成为治疗低位直肠癌的标准术式,ELAPE术式可能还需要进一步优化和改进.     

直肠癌术前放疗的疗效观察

目的 观察直肠癌术前放疗的临床效果。方法 对28例直肠癌病人进行术前放疗，观察肿块变化情况，不良反应，进行术后随访等。结果 放疗后肿块缩小，保肛率提高、局部复发率降低。结论 术前放疗可以减少复发率，提高切除率，增加保肛率，为直肠癌综合治疗的较佳方式。     

经直肠超声联合超声造影对直肠间质瘤与直肠癌的鉴别诊断价值

目的:探讨经直肠超声联合超声造影鉴别诊断直肠间质瘤与直肠癌的价值。方法:对已确诊的12例直肠间质瘤组常规超声及超声造影特点进行总结,并与24例直肠癌组的超声特征进行对比分析。结果:本组12例直肠间质瘤,其中低度危险程度间质瘤1例,中度危险程度间质瘤1例,高度危险程度间质瘤10例。直肠间质瘤组与直肠癌组在常规超声显示的肿瘤位置、大小、形态、边界、内部回声、周围淋巴结转移的差异均有统计学意义。直肠间质瘤的超声造影显示造影剂进入慢、退出快,且整体增强强度低。结论:直肠间质瘤常规超声及造影表现具有相对特征性,有助于提高直肠间质瘤与直肠癌的鉴别诊断价值。     

直肠癌住院病人心理状况及其心理需求的研究

目的：研究直肠癌住院病人的心理健康状况、心理需求特点,提出相应的护理干预措施。方法：采用“直肠癌住院病人一般资料调查表”、“症状自评量表”（SCL-90）,“直肠癌住院病人心理需要调查表”对60例诊断明确的直肠癌住院病人进行问卷调查,并将结果与健康人进行对照。结果：直肠癌住院病人在躯体化、强迫症状、抑郁、焦虑、敌对方面明显高于健康人,在人际关系敏感、恐怖、偏执、精神病性方面低于健康人。心理需求调查显示：尽早明确诊断、尽早手术治疗、医生技术精湛,手术成功是直肠癌住院病人的最主要心理需要。结论：研究直肠癌住院病人心理状况及其心理需求,可为整体护理的实施提供理论依据。     

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: Science,opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process.     

Clinicopathologic and prognostic significance of MMP-7 (matrilysin) expression in human rectal cancer

OBJECTIVE: There is increasing evidence to indicate that MMP-7 plays a more important role in tumor progression than other MMPs. The aim of this study was to detect MMP-7 expression in human rectal cancer and normal rectal tissue and to determine whether it is correlated with invasion and metastasis of human rectal cancer. METHODS: Eighty-six paired samples of rectal cancer and distant normal rectal tissue obtained from 100 inpatients were allocated into two groups (cancer group and control group). MMP-7 mRNA was detected by relative quantitative real-time RT-PCR and MMP-7 protein was examined by immunohistochemical staining and computerized image analysis. RESULTS: MMP-7 mRNA expression in cancer group was higher than that in control group (P = 0.006), the expression ratios of 31 samples (37.35%) were <1 and 52 (62.65%) were >1. The mRNA expression level was correlated with Dukes Staging, histological differentiation grade and CEA level. The MMP-7 protein expression was in accordance with mRNA expression level. The positive degree of immunohistochemical staining in cancer group (1.82 +/- 0.03) was different from that in control group (1.17 +/- 0.13, P = 0.002). Moreover, in cancer group the positive staining degree in high-level mRNA cancers (2.04 +/- 0.18, n = 52) was higher than that in low-level mRNA ones (1.58 +/- 0.23, n = 31, P = 0.008). CONCLUSIONS: Our results suggest that MMP-7 plays an important role in the progression of human rectal cancer. MMP-7 may be selected as a clinical diagnosis and prognosis index in rectal cancer.     

直肠癌的外科治疗进展

本文介绍直肠癌外科治疗的进展，探讨直肠癌外科治疗方面的一些重要问题，如保肛、膀胱和性功能的损伤和术后复发三个主要的难点。对于直肠癌手术的切缘问题、全系膜切除的概念、局部切除的手术指征、侧方淋巴结清扫的必要性以及直肠癌切除后结肠袋的重建等保肛手术，应把肿瘤的根治始终放在第一位，在不降低根治原则的前提下最大限度的提高保肛机率，应保证足够的下切缘和环形切缘；保护盆腔自主神经的手术的开展有利于减少膀胱和性功能的损伤；直肠癌的局部复发有很多因素值得考虑；直肠全系膜切除大大减少了直肠手术后的局部复发率；直肠肿瘤的局部切除应注意避免指征的过度扩大和缩小；侧方淋巴结清扫宜选择性开展；直肠癌切除后结肠袋的重建具有一定价值。     

Intake of wholegrain products and risk of colorectal cancers in the Diet,Cancer and Health cohort study

Background:

Consumption of wholegrain (WG) products may protect against colon and rectal cancer.

Methods:

The associations between total and individual WG product consumption and colon and rectal cancer risk were prospectively examined using data on 461 incident cases of colon cancer and 283 incident cases of rectal cancer that developed during 10.6 years (median) of follow-up among 26 630 men and 29 189 women taking part in the Diet, Cancer and Health cohort. Incidence rate ratios (IRRs) of colon and rectal cancer related to total or individual WG product intake were calculated using Cox regression.

Results:

Higher WG product intake was associated with lower risk of colon cancer and rectal cancer in men. The adjusted IRR (95% CI) was 0.85 (0.77–0.94) for colon cancer and 0.90 (0.80–1.01) for rectal cancer per daily 50 g increment in intake. For colon cancer the association was confined to intake of WG bread in particular. No consistent associations between total or individual WG product consumption and colon or rectal cancer risk were observed in women.

Conclusion:

The findings suggest that higher total WG product intake is associated with a lower risk of colon and perhaps rectal cancer in men, but not in women.     

External beam radiation treatment for rectal cancer is associated with a decrease in subsequent prostate cancer diagnosis

BACKGROUND: External beam radiation therapy (EBRT) for rectal cancer unavoidably delivers significant radiation dose to the prostate gland. The effect of this incidental exposure on subsequent prostate cancer diagnosis was investigated using the Surveillance, Epidemiology, and End Results (SEER) cancer registry. METHODS: Men diagnosed with localized or regional (L/R) rectal cancer from 1988-1997 and treated with EBRT and sphincter-sparing surgery (SSS) were identified. Men treated for L/R rectal cancer with SSS who did not receive EBRT, and men with L/R colon cancer who did not receive EBRT, were studied for comparison. Multiple Primary Standardized Incidence Ratios of observed to expected (O/E) cases of prostate cancer were calculated using SEER*Stat. RESULTS: In all, 1574 men with L/R rectal cancer treated with EBRT and SSS were identified. The median age at diagnosis was 64 and median survival was 76 months. Twenty were subsequently diagnosed with prostate cancer, a number significantly less than expected compared with the general population of similar age and race. The ratio of O/E cases was 0.28 (95% confidence interval [CI], 0.17, 0.43). In contrast, 3114 men diagnosed with rectal cancer undergoing SSS who were not treated with EBRT and 24,578 men diagnosed with colon cancer who were not treated with EBRT were subsequently diagnosed with prostate cancer at rates similar to the general population (O/E of 0.94 and 1.09). CONCLUSIONS: EBRT for L/R rectal cancer was associated with a 72% decrease in the frequency of subsequent prostate cancer diagnosis when compared with men of similar age and race. Possible mechanisms that may explain this observation are discussed.     

Comparison of risk factors for colon and rectal cancer

Predictors of colorectal cancer have been extensively studied with some evidence suggesting that risk factors vary by subsite. Using data from 2 prospective cohort studies, we examined established risk factors to determine whether they were differentially associated with colon and rectal cancer. Our study population included 87,733 women from the Nurses' Health Study (NHS) and 46,632 men from the Health Professionals Follow Up Study (HPFS). Exposure information was collected via biennial questionnaires (dietary variables were collected every 4 years). During the follow-up period (NHS: 1980 to May 31, 2000; HPFS: 1986 to January 31, 2000), we identified 1,139 cases of colon cancer and 339 cases of rectal cancer. We used pooled logistic regression to estimate multivariate relative risks for the 2 outcomes separately and then used polytomous logistic regression to compare these estimates. In the combined cohort, age, gender, family history of colon or rectal cancer, height, body mass index, physical activity, folate, intake of beef, pork or lamb as a main dish, intake of processed meat and alcohol were significantly associated with colon cancer risk. However, only age and sex were associated with rectal cancer. In a stepwise polytomous logistic regression procedure, family history and physical activity were associated with statistically significant different relative risks of colon and rectal cancer. Our findings support previous suggestions that family history and physical activity are not strong contributors to the etiology of rectal cancer. Future investigations of colon or rectal cancer should take into consideration risk factor differences by subsite.     

Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer

ObjectivesTo review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer.BackgroundThe management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures.MethodsA Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582).Results14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%–78%.LimitationsThe studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies.ConclusionsPelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.     

放疗联合希罗达治疗局部晚期直肠癌近期疗效

目的 观察放疗联合同步口服希罗达治疗局部晚期直肠癌的近期疗效和毒副反应.方法 选择局部晚期无手术指征或拒绝手术直肠癌和直肠癌术后局部复发患者50例,随机分为综合治疗组（23例,接受放疗联合希罗达）和单纯放疗组（27例,仅接受放疗）.结果 综合治疗组总有效率为87.0%,单纯放疗组为66.7%（P＜0.05）.综合治疗组放射性直肠炎发生率为26.1%,手足综合征为21.7%;单纯放疗组放射性直肠炎发生率为11.1%,对症治疗后均好转.结论 放疗联合希罗达治疗局部晚期直肠癌疗效确切、毒副反应较少,值得临床推广应用.     

红细胞分布宽度对根治性直肠癌切除术后预后评估的价值研究

目的:探讨红细胞分布宽度（red cell distribution width，RDW）与恶性直肠癌患者临床病理特征及预后的关系。方法:分析2010年到2013年在西安交通大学第一附属医院普通外科诊断为直肠癌并行根治性直肠癌切除术患者289例，通过收集患者临床病理及预后相关资料，经ROC曲线分析将患者分为高RDW组和低RDW组，比较两组患者术后近远期疗效。结果:不同RDW组别间患者一般资料比较未见统计学差异。而高RDW组患者肿瘤直径较大、肿瘤更易发生淋巴脉管浸润且术前巨噬细胞较高（P＜0.05）。高RDW组患者3年总生存率及3年无病生存率均较低RDW组差。进一步通过COX回归分析发现N分期、淋巴脉管浸润、肿瘤分化程度和RDW为根治性直肠癌切除术后患者3年总生存率的独立危险因素。结论:RDW是直肠癌预后的独立危险因素，可作为直肠癌患者预后评估指标之一。     

直肠癌的局部切除术

早期直肠癌的局部切除术同经腹部的切除术相比具有手术风险低、手术创伤小、术后无性功能和泌尿功能的障碍等多项优点，并能最大程度上予以保留肛门。但由于手术指征掌握不同、手术入路和手术方法各异，导致最终手术疗效上的差别悬殊。因此严格掌握手术指征，选择适当的手术路径和技术，保证局部切除的根治性是早期直肠癌局部切除术取得优良疗效的关键。     

经双吻合器直肠拖出式切除吻合行超低位直肠癌保肛术的疗效

目的探讨在超低位直肠癌保肛术中实施经双吻合器直肠拖出式切除吻合的疗效。方法选择实施经双吻合器直肠拖出式切除吻合手术治疗的62例超低位直肠癌患者为研究组,选取同期经腹直肠前切除吻合术患者58例为对照组,比较两组患者的结果。结果所有患者经双吻合器直肠拖出式切除吻合全部成功,两组患者复发情况、生存情况相近,差异无统计学意义。研究组术后6个月的肛门功能明显优于对照组,两组12个月的肛门功能情况相近。结论在超低位直肠癌保肛术中,实施经双吻合器直肠拖出式切除吻合有一定优势,值得推广应用。     

低位直肠癌行保肛手术的体会

目的为提高低位直肠癌保肛手术的治疗效果,减少术后局部复发,免除因人工肛门给病人造成的痛苦。方法对５７例肿瘤位于盆底腹膜返折处或以下的低位直肠癌保肛手术进行回顾性分析。其中行Ｄｉｘｏｎ前切除术４７例,Ｂａｃｏｎ拖出术２例,Ｐａｒｋｓ结肠肛管吻合术２例,经腹骶直肠癌切除术２例,经肛门局部切除术４例。结果术后局部复发者１４例占２４．７％,局部复发中盆腔内复发９例,吻合口复发２例,腹股沟淋巴结转移１例,会阴部及坐骨直肠窝内复发２例。术后肝转移６例,肺转移２例,骨转移１例。五年无瘤生存率为６４．９％。结论对于低位直肠癌只要满足根治性手术切除的条件应尽可能争取行保肛手术。距肿瘤边缘２－３ｃｍ切断直肠是安全可靠的。强调适当扩大盆腔内切除范围是减少术后局部复发的关键。     

Fertility Preservation Discussions Between Young Adult Rectal Cancer Survivors and Their Providers: Sex-Specific Prevalence and Correlates

BackgroundYoung adults (YA) diagnosed with rectal cancer are disproportionately impacted by the gonadotoxic effects of treatment and potential subsequent infertility.ObjectiveThe purpose of this study was to characterize the prevalence of fertility preservation measures used, reasons why such measures were not used, and correlates of discussion between providers and YA rectal cancer survivors.DesignAn online, cross-sectional survey was administered on the Facebook page of a national colorectal cancer (CRC) advocacy organization. Eligible participants were rectal cancer survivors diagnosed before age 50, between 6 and 36 months from diagnosis or relapse, and based in the US.ResultsParticipants were 148 rectal cancer survivors. Over half of the survivors reported that their doctor did not talk to them about potential therapy-related fertility complications. Only one-fifth of survivors banked sperm (males) or eggs/embryos (females) prior to their cancer therapy. Older age at diagnosis and greater quality of life were significantly associated with a higher likelihood of fertility discussions among males. Greater quality of life was significantly associated with a higher likelihood of fertility discussion among females.ConclusionsThese findings indicate that the majority of YA rectal cancer survivors do not receive, or cannot recall, comprehensive cancer care, and help to identify patients with rectal cancer who may be at risk for inadequate fertility counseling. Clinicians should provide proper counseling to mitigate this late effect and to ensure optimal quality of life for YA rectal cancer survivors.     

直肠癌新辅助治疗后临床完全缓解的评估

新辅助治疗已成为局部晚期直肠癌的标准治疗模式。新辅助治疗后对肿瘤反应进行评估及再分期对于制定患者后续的治疗策略和预测肿瘤的预后至关重要。有一部分患者在新辅助治疗后能达到临床完全缓解甚至病理完全缓解,而在病理未明确之前如何评估临床缓解一直是目前国内外专家关注的焦点。本文就直肠癌新辅助治疗后的最佳评估时间和评估方法的进展进行综述。     

Comparisons between the KKU-Model and Conventional Rectal Tubes as Markers for Checking Rectal Doses during Intracavitary Brachytherapy of Cervical Cancer

Background: To compare the KKU-model rectal tube (KKU-tube) and the conventional rectal tube (CRT) for checking rectal doses during high-dose-rate intracavitary brachytherapy (HDR-ICBT) of cervical cancer. Materials and Methods: Between February 2010 and January 2011, thirty -two patients with cervical cancer were enrolled and treated with external beam radiotherapy (EBRT) and intracavitary brachytherapy (ICBT). The KKU-tube and CRT were applied intrarectally in the same patients at alternate sessions as references forcalculation of rectal doses during ICBT. The gold standard references of rectum anatomical markers which are most proximal to radiation sources were anterior rectal walls (ARW) adjacent to the uterine cervix demonstrated by barium sulfate suspension enema. The calculated rectal doses derived from actual anterior rectal walls, CRT and the anterior surfaces of the KKU-tubes were compared by using the paired t-test. The pain caused by insertion of each type of rectal tube was assessed by the visual analogue scale (VAS). Results: The mean dose of CRT was lower than the mean dose of ARW (Dmean0-Dmean1) by 80.55±47.33 cGy (p-value <0.05). The mean dose of the KKU-tube was lower than the mean dose of ARW (Dmean0-Dmean2) by 30.82±24.20 cGy (p-value <0.05). The mean dose difference [(Dmean0-Dmean1)-(Dmean0-Dmean2)] was 49.72±51.60 cGy, which was statistically significant between 42.32 cGy -57.13 cGy with the t-value of 13.24 (p-value <0.05). The maximum rectal dose by using CRT was higher than the KKU-tube as much as 75.26 cGy and statistically significant with the t-score of 7.55 (p-value <0.05). The mean doses at the anterior rectal wall while using the CRTs and the KKU-tubes were not significantly different (p-value=0.09). The mean pain score during insertion of the CRT was significantly higher than the KKU-tube by a t-score of 6.15 (p-value <0.05) Conclusions: The KKU-model rectal tube was found to be an easily producible, applicable and reliable instrument as a reference for evaluating the rectal dose during ICBT of cervical cancer without negative effects on the patients.