Prognostic Value of Quality of Life and Pain in Patients with Locally Recurrent Rectal Cancer

Background

Care of patients with locally recurrent rectal cancer (LRRC) requires careful patient selection. While curative resection offers survival benefits, significant trade-offs exist for the patient. Knowledge of patient-reported outcomes will help inform treatment decisions.

Methods

Quality of life (QOL) and pain were prospectively assessed in 105 patients treated for LRRC at a single institution, using the validated Functional Assessment of Cancer Therapy-Colorectal (FACT-C) and Brief Pain Inventory (BPI) questionnaires. In 54 patients enrolled and followed from diagnosis of LRRC, relationship between pretreatment pain, QOL, and overall survival (OS) were examined.

Results

Patients underwent curative surgical resection (C, 59%), noncurative surgery (NC, 12%) or nonsurgical treatment (NS, 28%). Median OS was 7.1, 1.4, and 1.9 years, respectively (C versus NC: p < 0.001; C versus NS: p = 0.006; NC versus NS: p = 0.261). Physical well-being QOL differed over time (p = 0.042), with greatest difference between C and NC surgery patients (p = 0.049). The remaining QOL domain scores and pain scores demonstrated no significant time or treatment effect. For the 54 patients assessed from diagnosis, median OS was independently predicted by treatment group (C, NC, NS: 4.3, 1.7, versus 2.4 years; p < 0.001) and pretreatment pain intensity (score ≤ 4 versus > 4: 3.8 versus 2.0 years; p = 0.001).

Conclusion

Curative surgery offered prolonged survival, but significant pain exists among long-term survivors and should be a focus of survivorship care. Noncurative surgery did not offer apparent advantages over nonsurgical palliation. Patient’s pretreatment pain has prognostic value, and should be assessed, treated, and considered in treatment decisions.     

腹腔镜超低位直肠癌经腹会阴联合切除会阴人工肛门重建术的疗效观察

目的探讨腹腔镜超低位直肠癌经腹会阴联合切除会阴人工肛门重建术的安全性和临床疗效。方法回顾性分析2006年4月至2010年2月期间解放军第150中心医院全军肛肠外科研究所收治的102例超低位直肠癌行经腹会阴联合切除会阴人工肛门重建术的患者,其中腹腔镜手术58例（腹腔镜组）,开腹手术44例（开腹组）。观察指标包括手术时间、术中失血量、检出淋巴结数目、术后恢复流质饮食时间、术后首次肛门排气时间、术后住院时间、术后并发症等;采用Kaplan-Meier法计算生存率并经log-rank检验,计量资料采用t检验,计数资料采用χ2检验。结果腹腔镜组和开腹组的一般临床病理资料比较差异均无统计学意义（P〉0.05）。2组均顺利完成手术,无与手术相关的死亡病例。腹腔镜组的手术时间略长于开腹组,但差异无统计学意义（P〉0.05）;腹腔镜组的术中失血量明显少于开腹组,差异有统计学意义（P〈0.05）;腹腔镜组的术后首次肛门排气时间、术后恢复流质饮食时间及术后住院时间均明显短于开腹组,差异均有统计学意义（P〈0.05）;腹腔镜组检出淋巴结枚数明显多于开腹组,差异有统计学意义（P〈0.05）。2组并发症发生率比较,差异无统计学意义（P〉0.05）。2组患者的生存曲线比较,差异无统计学意义（P=0.897）。结论腹腔镜超低位直肠癌经腹会阴联合切除会阴人工肛门重建手术与开腹直肠癌手术能达到同样的疗效,且其创伤小、术后恢复快、安全可行。     

腹腔镜与开腹直肠癌Miles手术对会阴部伤口愈合的影响

目的比较腹腔镜辅助与开腹直肠癌Miles根治术对会阴部伤口愈合的影响。方法收集2008年1月至2009年12月期间我院行腹腔镜Miles根治术的54例(腹腔镜组)及行开腹Miles根治术的48例(开腹组)直肠癌患者的临床资料,比较2组患者会阴部伤口的甲级愈合率、全程手术时间、会阴部手术时间、术中出血量、术后骶前引流量及术后第3天血白蛋白水平的差异。结果 2组患者在性别、年龄、肿瘤Dukes分期、术前白蛋白水平及术前合并症方面差异均无统计学意义(P0.05)。腹腔镜组的会阴部伤口甲级愈合率(2χ=5.54,P0.05)及术后第3天血白蛋白水平(t=3.92,P0.01)均明显高于开腹组。腹腔镜组会阴部手术时间(t=6.64,P0.01)、术中出血量(t=6.05,P0.01)和术后骶前引流量(t=12.86,P0.01)均明显短于或少于开腹组。结论腹腔镜辅助Miles根治术较开腹Miles手术具有更高的会阴部伤口甲级愈合率,这可能与腹腔镜手术创伤小、出血少及会阴部手术时间更短有关。     

记忆合金支架在直肠癌伴梗阻患者中的应用

目的 探讨记忆合金支架治疗直肠癌伴梗阻的疗效及意义。方法 对21例直肠恶性狭窄导致的急、慢性梗阻患者施行了支架置入术。支架在冰水中柔软，易压缩，通过徒手或乙状结肠镜送至狭窄部位，灌注热水后支架复形扩张。结果 18例患者成功置入，有效地恢复了排便。3例置入失败，改行结肠造口。带支架的患者中现已死亡14例，生存期56－720天；其他4例已存活2－15个月，未再发肠梗阻。结论 记忆合金支架能有效地缓解直肠癌导致的急、慢性梗阻，可对晚期直肠癌及有高危手术因素的患者行永久性姑息治疗，避免结肠造口。配合化疗和免疫治疗，有利于延长患者生存期。     

A Population-Based Study on the Management and Outcome in Patients with Locally Recurrent Rectal Cancer

Background Although outcome in patients with rectal cancer has improved with preoperative radiotherapy and total mesorectal excision, local recurrence still remains a problem. The condition is difficult to cure and little is known on whether the prognosis for patients with locally recurrent tumours has changed over time. Few population-based studies have been performed. Method Two thousand three hundred and eighteen patients in Stockholm, Sweden had a potentially curative resection for rectal cancer between 1995 and 2003. Until 2005, 141 (6%) developed a local recurrence. Management and outcome for these patients were studied and compared to a previously analysed cohort of 156 patients with local recurrence, treated 1980–1991. Results Of the 141 patients, 57 (40%) had surgery with a curative intent, 48 (34%) radio- and/or chemotherapy and 36 (26%) symptomatic palliation only. The total 5-year survival was 9%. Twenty-five patients had a potentially curative resection, with a 5-year survival of 57%. The corresponding figures for the 156 patients in the earlier cohort were 4 and 42%. Conclusion Although outcome for patients with local recurrence of rectal cancer is dismal, the prognosis has improved slightly over time. A radical resection is a prerequisite for cure and the proportion having a potentially curative resection has increased. Multidisciplinary management, including optimised preoperative staging and patient selection for surgery, radical surgical approach and more effective adjuvant treatments are necessary to further improve the prognosis. Source of financial support: The Cancer Society in Stockholm.     

Modified Gluteus Maximus V-Y Advancement Flap for Reconstruction of Perineal Defects After Resection of Intrapelvic Recurrent Rectal Cancer: Report of a Case

Technical advances in myocutaneous flap preparation have resulted in primary reconstruction now being generally indicated for malignant tumors extensively infiltrating the pelvic cavity and perineum. Pelvic tumor resection can dramatically improve the health-related quality of life (QOL) of patients with locally recurrent rectal cancer complicated by infection and pain. However, the removal of a wide area of perineum by these two procedures often leaves a large dead space. A gluteal thigh muscle, rectus abdominis muscle, or pedicle myocutaneous flap is usually made to reconstruct such extensive perineal defects. The subject of this case report was a 76-year-old woman with recurrent rectal cancer in the pelvis after abdominoperineal resection. The large pelvic tumor, which was causing severe pain, was resected and the extensive perineal defects were reconstructed using a modified maximus V-Y advancement flap. The operating time was approximately 30min, and the pain after surgery was much less severe. Moreover, she could walk the day after surgery and returned to normal daily life without requiring prolonged bed rest. No infection developed in the intrapelvic dead space postoperatively. This technique proved very useful for improving the patient's QOL.     

Nerve-sparing Surgery for Advanced Rectal Cancer Patients: Special Reference to Dukes C Patients

Several nerve-sparing operations for advanced rectal cancer that aim to preserve genitourinary function without compromising tumor clearance have been developed in Japan. The aim of this study was to evaluate the survival and local recurrence of these procedures in Dukes B and C patients. A total of 177 patients with advanced rectal cancer underwent curative nerve-sparing surgery (NSS) over the last 11 years; 52 were Dukes B patients and 54 were Dukes C. Altogether 36 had Dukes C1 and 18 had Dukes C2 tumors, 13 with lateral lymph node metastases, designated lateral LN(+). The 5-year survival rate was 92% for Dukes B, 67% for Dukes C1, and 39% for Dukes C2 patients: 11% for Dukes C2 patients with lateral LN(+). The local recurrence rate was 6% for Dukes B, 11% for Dukes C1, and 33% for Dukes C2 patients: 20% for the lateral LN(−) group and 39% for the lateral LN(+) group. Almost all of the patients undergoing NSS could micturate spontaneously, but preservation of sexual function was not as successful. Although there is no guarantee of preserving satisfactory sexual function, our NSS is an acceptable procedure for Dukes B, C1, and C2 patients without lateral lymph node metastases.     

三维适形放射治疗联合替吉奥化学治疗局部复发性直肠癌32例

目的观察三维适形放射治疗(放疗)联合替吉奥化学治疗(化疗)局部复发直肠癌的安全性与可行性。方法32例经证实的局部复发直肠癌患者接受全盆腔三维适形放疗DT45Gy/25F,后缩野至肿瘤复发区推量至63Gy/35F,同期口服替吉奥胶囊80 mg·(m2)-1·d-1(d1～5,d8～12,d15～19,d22～26,d29～33,d36～40,d43～47)。结果有1例患者口服替吉奥胶囊1周后出现4级血小板下降,停用化疗,只完成放疗,其他患者均完成放疗和化疗。32例患者中,完全缓解3例(9.4%),部分缓解21例(65.6%),总有效率为75.0%;1和2年生存率分别为71.0%和56.5%;疼痛缓解率为96.9%。主要毒性反应为消化道反应和血液学毒性,有1例出现4级血小板下降,有2例出现3级白细胞下降,有1例出现3级腹泻,3～4级毒性反应发生率为12.5%。结论三维适形放疗联合替吉奥化疗治疗局部复发性直肠癌方法,近期疗效可靠,患者依从性好,毒性反应可耐受。     

Predictors for Complications after Loop Stoma Closure in Patients with Rectal Cancer

Purpose This unmatched case control study was undertaken to evaluate factors contributing to surgery-related complications of loop stoma closure in patients with rectal cancer. Methods Cases were consecutive patients with complications identified from a local registry. Complications were defined as surgery-related and included 30 days overall mortality. Controls were all other patients with stoma closure from the same population of the registry without the endpoint. Results Of the 243 patients, 47 (19%) patients experienced a surgery-related complication, including 5 patients who died within 30 days after surgery. Significant risk factors in the univariate analysis were supervised operation (odds ratio 0.50; 95% confidence interval 0.27–0.95; P = 0.04), stapled anastomosis (odds ratio 0.40; 95% confidence interval 0.17–0.91; P = 0.04) and using a soft silicone drain (odds ratio 2.03; 95% confidence interval 1.07–3.85; P = 0.04). Using a soft silicone drain (odds ratio 2.17; 95% confidence interval 1.10–4.26; P = 0.03) and stapled anastomosis (odds ratio 0.38; 95% confidence interval 0.15–0.98; P = 0.04) were the only significant predictors in the multivariate analysis. Conclusions The present study in a homogeneous group of patients with rectal cancer as elective indication for temporary loop stoma construction confirms the high complications rate and mortality rate associated with stoma closure. Intraperitoneal drains should be omitted after loop stoma closure.     

Perineal Healing and Survival After Anal Cancer Salvage Surgery: 10-Year Experience with Primary Perineal Reconstruction Using the Vertical Rectus Abdominis Myocutaneous (VRAM) Flap

Salvage surgery of recurrent or persistent anal cancer following radiotherapy is often followed by perineal wound complications. We examined survival and perineal wound complications in anal cancer salvage surgery during a 10-year period with primary perineal reconstruction predominantly performed using vertical rectus abdominis myocutaneous (VRAM) flap. Between 1997 and 2006, 49 patients underwent anal cancer salvage surgery. Of these, 48 had primary reconstruction with VRAM. Overall survival was computed by the Kaplan–Meier method and mortality rate ratios (MRRs) by Cox regression. One patient (2%) died within 30 days postoperatively. Postoperative complications necessitated reoperation in eight (16%) patients. We found no major perineal wound infections. Major perineal wound breakdown occurred in the only patient in whom VRAM was not used. Five-year survival was 61% [95% confidence interval (CI) 43–75%]. Free resection margins (R0) were obtained in 78% of patients, with 5-year survival of 75% (95% CI 53–87%). Involved margins, microscopically only (R1) or macroscopically (R2), strongly predicted an adverse outcome [age-adjusted 2-year MRRs (95% CI) R1 vs. R0 = 4.1 (0.7–23.6), R2 vs. R0 = 10.9 (2.2–54.2)]. We conclude that anal cancer salvage surgery can yield long-time survival but obtaining free margins is critical. A low rate of perineal complications is achievable by primary perineal reconstruction using VRAM flap.     

Radical Resection After IORT-Containing Multimodality Treatment is the Most Important Determinant for Outcome in Patients Treated for Locally Recurrent Rectal Cancer

Background  The optimal treatment for locally recurrent rectal cancer (LRRC) is still a matter of debate. This study assessed the outcome of LRRC patients treated with multimodality treatment, consisting of neoadjuvant radio (chemo-) therapy, extended resection, and intraoperative radiotherapy. Methods  One hundred and forty-seven consecutive patients with LRRC who underwent treatment between 1994 and 2006 were studied. The prognostic values of patient-, tumor- and treatment-related characteristics were tested with uni- and multivariate analysis. Results  Median overall survival was 28 months (range 0-146 months). Five-year overall, disease-free, and metastasis-free survival and local control (OS, DFS, MFS, and LC respectively) were 31.5%, 34.1%, 49.5% and 54.1% respectively. Radical resection (R0) was obtained in 84 patients (57.2%), microscopically irradical resection (R1) in 34 patients (23.1%), and macroscopically irradical resection (R2) in 29 patients (19.7%). For patients with a radical resection median OS was 59 months and the 5-year OS, DFS, MFS, and LC were 48.4%, 52.3%, 65.5% and 68.9%, respectively. Radical resection was significantly correlated with improved OS, DFS, and LC (P < 0.001). Patients who received re-irradiation or full-course radiotherapy survived significantly longer (P = 0.043) and longer without local recurrence (P = 0.038) or metastasis (P < 0.001) compared to patients who were not re-irradiated. Conclusions  Radical resection is the most significant predictor of improved survival in patients with LRRC. Neoadjuvant radio (chemo-) therapy is the best option in order to realize a radical resection. Re-irradiation is feasible in patients who already received irradiation as part of the primary rectal cancer treatment.     

前列腺癌骨转移性疼痛的综合治疗

目的 :探讨晚期前列腺癌骨转移性疼痛的综合治疗方法。　方法 :16例确诊为前列腺癌且有多个部位骨转移病灶伴有疼痛的患者 ,采用口服抗雄激素药物治疗的同时 ,辅以核素89Sr静脉内注射治疗和部分病灶放射治疗。　结果 :治疗后 ,疼痛缓解率 3个月为 75 .6 % ,6个月为 80 .5 % ,9个月为 6 3.4 % ;骨转移病灶数量明显减少。结论 :经过综合治疗后 ,本组晚期前列腺癌伴骨转移性疼痛的患者疼痛获得较为满意的缓解、甚至消失 ,从而改善了患者的生活质量。     

Laparoscopic Pelvic Autonomic Nerve-Preserving Surgery for Patients with Lower Rectal Cancer after Chemoradiation Therapy

Objective This is a phase II study, the aim of which is to determine if a laparoscopic approach can be used in pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer following chemoradiation therapy. Methods Patients with T3 lower rectal cancer treated by preoperative chemoradiation were recruited and subjected to laparoscopic pelvic autonomic nerve-preserving surgery with total mesorectal excision and a sphincter-saving procedure. This study was performed with the approval of the ethics committee of National Taiwan University Hospital. Because the quality of a surgical trial is highly dependent on the skill of the surgeon with respect to the technique under study, it is imperative that a surgical trial only be implemented after the surgical technique has been judged to be mature. Before the start of this clinical trial, we gained a sound knowledge of surgical anatomy through conventional open surgery for rectal cancer and mastered the related laparoscopic skills from other sound and proven laparoscopic approaches, including right hemicolectomy, left hemicolectomy, among others. We determined that the learning curve for this surgical technique necessitated that colorectal surgeons carry out at least 20 such procedures. At this point we conducted this clinical trial. The details of the surgical procedures have been shown in the attached video. Briefly, the dissection commences at the pelvic promontory with exposure and preservation of the superior hypogastric plexus. The pre-aortic plexus and inferior mesenteric plexus are preserved by sparing the pre-aortic connective tissue and leaving a 1– to 2-cm-long stump of the inferior mesenteric artery in situ. Subsequently, the “holy plane” at the transition of the mesosigmoid to the mesorectum is meticulously dissected to progressively displace the hypogastric nerves dorsally and laterally and, therefore, preserving them. Following adequate dorsal and lateral dissection down to the floor of the pelvis, the so-called lateral ligament is reached at which the mesorectum appears to be adherent, anteriorly and laterally, to the inferior hypogastric plexus (at roughly 10:00–2:00 O’clock or within an angle of 60° about symphysis on both sides). The ligaments are divided immediately at the endopelvic fascia of the mesorectum to avoid damage to the inferior hypogastric plexus (pelvic plexus). Finally, great care was taken to dissect the lateral border of Denonvilliers’ fascia where the inferior hypogastric plexus joins the neurovascular bundle described by Walsh. Postoperatively, only patients successfully operated on by total pelvic autonomic nerve-preserving surgery were included in the statistical analysis of surgical outcomes. Preoperatively, all patients were screened for their genitourinary function by a questionnaire-based interview. Patients with abnormal preoperative baseline functional data were excluded from further postoperative assessment of sexual or urinary function. The male sexual function was evaluated by potency and ejaculation. In female patients, the sexual function was assessed by vaginal lubrication, dyspareunia, sexual arousal, and orgasm. The reason for these four parameters is because the influence of pelvic autonomic nerve damage on female sexual function has been ambiguous but would most likely result in impairment of vaginal lubrication and congestion of the genitals. We evaluated sexual function at 6 months postoperatively, when the temporary colostomy had been closed and the patients were completely recovered from surgical disability. In evaluating urinary function, the duration between initial voiding trial and spontaneous voiding was recorded. The questionnaire used for the assessment of urinary dysfunction was based on the International Prostate Symptom Score and the following parameters from this Score were used: incomplete emptying, frequency, intermittency, urgency, week stream, straining, and nocturia. Any voiding problems recovered within 3 months after the operation were considered to be transient bladder voiding dysfunction; all other voiding problems were deemed persistent. The interview and scoring of the questionnaire were done by the research assistant blinded to operation procedures. The genitourinary function was ranked as good, fair (decreased), and poor (impaired). Results Between June 2003 and December 2005, a total of 98 patients (stage II: n = 44; stage III: n = 54; male: n = 50; female: n = 48) were enrolled in this study. Technically, although the dissection plane is a little blurred by preoperative chemoradiation therapy, the laparoscopic pelvic nerve-preserving procedure with total mesorectal excision was successfully performed in 89 (90.8%) patients with an acceptable operation time (284.4 ± 44.8 minutes; mean ± standard deviation) and little blood loss (114.5 ± 24 ml). The number of dissected lymph nodes was 16.4 ± 4.0. With respect to scrutiny of surgical specimens, the distal safety margin was adequate (mean: 2.4 cm; range: 1.2–5.6 cm), and the circumferential resection margins were free of tumor invasion (mean: 8.6 mm; range: 2–18 mm). A total of 74 patients completed the evaluation of urinary function. For these 74 patients, the median duration of training for the Foley catheter was 7 days (range: 4–64 days). The voiding function after removal of the Foley catheter were good in 53 (71.6%) patients, fair in 17 (23.0%), and poor in four (5.4%). Of the 17 patients with fair bladder function, eight were transient dysfunction and recovered thereafter. Thirty-two male and 28 female patients who were sexually active before the operation responded to the assessment of sexual function. In male patients, the ejaculation was good in 18 (56.3%) patients, fair (decrease in ejaculatory amounts) in six (18.7%), and poor (retrograde ejaculation, failure to ejaculate) in eight (25%). The potency was good in 20 (62.5%) patients, fair in five (15.6%), and poor in seven (21.9%). In female patients, the sexual function was good in 15 (53.6%) patients, fair in four (14.3%), and poor in nine (32.1%). Specific sexual problems in women included lubrication (46.6%, n = 13), dyspareunia (39.2%, n = 11), sexual arousal (28.6%, n = 8), and orgasm in (32.1%, n = 9). Conclusions By the laparoscopic approach, total preservation of pelvic autonomic nerves without compromise of the radical extirpation of tumor is technically feasible in the vast majority of patients with lower rectal cancer who have undergone concurrent chemoradiation therapy, thus facilitating the retention of genitourinary function in a significant proportion of such patients. Supplementary material is available in the online version of this article at and is accessible for authorized users.     

Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

Background

After abdominoperineal excision (APE), the presence of tumor cells in the circumferential resection margin (R1) and iatrogenic tumor perforations are still frequent and result in an increased rate of local recurrences. In this study, a standardized supine APE with an increased focus on the perineal dissection (sPPD) is compared to the customary supine APE.

Methods

From 2000 to 2010, a total of 246 patients underwent APE for rectal cancer (sPPD and customary supine APE). All patients were staged with preoperative magnetic resonance imaging (MRI) and received neoadjuvant treatment (n?=?203) when margins were involved or threatened (cT3?+?and T4). As a result of a quality improvement program in 2006, the surgical technique was modified: it became standardized, emphasis was placed on the perineal dissection, and pelvic dissection was limited to avoid false routes when following the total mesorectal excision planes deep into the pelvis.

Results

Overall, the percentage of involved circumferential resection margins (CRMs) was 10%. In the period before introducing sPPD, the R1 percentages for cT0?C3 and cT4 tumors were 6.8 and 30.2%, compared to 2.2 and 5.7% after introduction of sPPD (P?=?0.001). Risk factors for R1 resection were preoperative T4 tumors (14.9%, P?=?0.011), tumor perforation (33.3%, P?=?0.002), fistulating tumors (35.7%, P?=?0.002), mucus-producing tumors (23.1%, P?=?0.006), or bulky tumors (66.7%, P?Conclusions The objective of surgical treatment of low rectal cancer is to obtain negative resection margins and subsequently reduce the risk of local recurrence. A combination of the appropriate preoperative treatment and standardized surgical technique such as sPPD can achieve this goal.     

A Stepwise Approach to Transanal Endoscopic Microsurgery for Rectal Cancer Using a Single-Incision Laparoscopic Port

Background

Radical rectal resection with total mesorectal excision is the current standard of care for the operative treatment of rectal cancer. Local excision is an acceptable alternative in selected patients with early disease (T_is0?T₁) and low-risk features, in whom radical resection may be associated with unacceptably high morbidity. With recent data demonstrating favorable results in well-selected patients, the role of local excision for rectal cancer is expanding.1 ^, 2 Transanal endoscopic microsurgery (TEM), which requires the use of an operating anoscope, has been used for the local excision of mid-upper rectal tumors. We describe an alternative approach to TEM for rectal cancer.

Methods

We present a stepwise technique for TEM using a single-incision laparoscopic (SILS) port. The patient is a 64 year-old male with a right anterolateral rectal polyp 7?cm from the anal verge, which on snare polypectomy demonstrated in-situ carcinoma with positive margins. Endoscopic ultrasound demonstrated uT₁ disease with no lymphadenopathy. He opted for local excision and underwent TEM. Our stepwise approach includes: (1) delineation of excision margins, (2) full thickness incision of the rectal wall, (3) circumferential dissection, and full thickness excision, and (4) suture repair.

Results

The procedure was performed without intraoperative or postoperative complications. Final pathology revealed in-situ carcinoma with widely negative margins. At 1- and 3-week follow-up visits, the patient was pain free with normal bowel activity and no rectal bleeding or genitourinary dysfunction.

Discussion

TEM using a SILS port is an effective technique for the local excision of mid-upper rectal cancer in well-selected patients.     

Early and Late Outcomes of Surgery for Locally Recurrent Rectal Cancer: A Prospective 10-Year Study in the Total Mesorectal Excision Era

Annals of Surgical Oncology - The aim of this study was to assess the outcome of all locally recurrent rectal cancer (LRRC) patients who were referred to a tertiary care center. The study examined...