Outcome of Total Pelvic Exenteration for Primary Rectal Cancer

PURPOSE: This retrospective study identifies the clinicopathologic factors (age, gender, size of tumor, location, tumor stage, lymph node metastasis, histologic differentiation, and adjuvant therapies) that are useful in predicting long-term survival in patients undergoing total pelvic exenteration for advanced primary rectal cancer. METHODS: We reviewed the medical records of 71 patients with stage T3 or T4 primary rectal cancer who underwent a curative total pelvic exenteration. The effects of various clinical variables on long-term survival were analyzed. RESULTS: The postoperative mortality, hospital death, and morbidity rates were 1.4, 4.2, and 66.2 percent, respectively. The overall five-year survival rate after total pelvic exenteration was 54.1 percent. The five-year survival rate was 65.7 percent for patients with T3 lesions and 39 percent for patients with T4 lesions. A univariate analysis showed that postoperative survival was affected by age, tumor stage, and lymph node metastasis, while a multivariate analysis showed that age and lymph node metastasis were independent prognostic factors. CONCLUSION: Total pelvic exenteration may enable long-term survival in younger patients with stage T3 or T4 primary rectal cancer and little or no lymph node metastasis.     

Pelvic Exenteration and Sacral Resection for Locally Advanced Primary and Recurrent Rectal Cancer

PURPOSE: The only possibility of a surgical cure in patients with locally advanced primary or recurrent rectal cancer would be an extended resection such as pelvic exenteration and sacral resection. The aim of this study was to evaluate the safety, tolerability, and survival benefits of these procedures. METHODS: Between 1988 and 1999, 64 patients with locally advanced primary or recurrent rectal cancer underwent abdominoperineal resection, with sacral resection in 9 patients, anterior pelvic exenteration in 8 patients, total pelvic exenteration in 27 patients, and total pelvic exenteration with sacral resection in 20 patients. RESULTS: Rates of morbidity, reoperation, and mortality were 50, 4.5, and 0 percent in 22 patients with primary cancer, and 60, 2.4, and 2.4 percent in 42 patients with recurrent disease, respectively. Major complications, such as sepsis, intra-abdominal abscess, and enteric fistula caused one hospital death and reoperation in two patients. In 21 patients who underwent curative resection for primary cancer, the overall five-year survival rates were 74.1 percent for Dukes B and 47.4 percent for Dukes C, although the difference was not statistically significant. Thirty patients with recurrent cancer who underwent curative resection had significantly improved survival, with a five-year survival rate of 22.9 percent, compared with 12 patients who underwent palliative resection, resulting in a survival rate of 0 percent (P = 0.0065). CONCLUSIONS: Pelvic exenteration and sacral resection for primary or recurrent rectal cancer are tolerable procedures with a low mortality rate. Although they provide a survival benefit if curative resection is possible, the associated morbidity remains high and should be followed up closely.     

Outcome of total pelvic exenteration for locally recurrent rectal cancer

BACKGROUND/AIMS: Local recurrence occurs in 10 to 30% of patients with rectal cancer following curative resection. However treatment of choice remains controversial. We assessed the results of total pelvic exenteration for locally recurrent cancer of the rectum retrospectively. METHODOLOGY: We reviewed medical charts of 45 patients with rectal cancer who underwent curative total pelvic exenteration for local recurrence. The cause of recurrence was classified into four groups: anastomotic, surgical cut-end, implantation, and lymphatic based on pathologic findings and computed tomography. Long-term survival was correlated with clinicopathologic variables. RESULTS: Postoperative morbidity was 77.8% and in-hospital death occurred in 13.3% of patients. The overall 5-year survival rate was 14.1%. The 5-year survival rates stratified according to the expectation of curability were 31.6% for absolutely curative resection, 7.8% for relatively curative resection, and 0% for non-curative resection. Multivariate analysis revealed that the disease-free interval was the only independent prognostic factor. There was no benefit from perioperative radiation or intraoperative continuous pelvic peritoneal perfusion of the pelvis. CONCLUSIONS: Total pelvic exenteration for local recurrence of rectal cancer can achieve long-term survival when curative resection is possible and the disease-free interval is long.     

Abdominosacral resection of recurrent rectal cancer in the sacrum

PURPOSE: Resection of the sacrum is the only curative therapy of isolated sacral recurrence after primarily resected rectal cancer. The aim of the study was to assess whether there is a benefit in terms of overall survival, morbidity, and mortality when sacrum resection is performed more radically and in cooperation between colorectal and orthopedic surgeons. Possible prognostic factors were also assessed. METHODS: Twelve consecutive patients who underwent interdisciplinary partial sacral resection were included in a retrospective cohort study. Furthermore, overall survival rate and survival time were calculated. RESULTS: Histologic examination showed tumor-free resection margins in all cases. Extended resection was necessary in seven patients, including total pelvic exenteration in two. No perioperative death occurred and no patient required early reoperation. Complications were observed in 42 percent of patients, mainly caused by poor wound healing. All patients experienced relief from pain. One-year and three-year overall survival rates were 50 and 17 percent, respectively. The overall mean survival time was 21.7 months. Patients who died of recurrent disease within one year either underwent former resection for locoregional recurrence, had extensive local recurrent tumors affecting pelvic visceral structures, or retrospectively suffered from metastatic sacral tumor manifestation. CONCLUSION: The mortality and morbidity rates observed in the present study seem to justify partial sacral resection as a means to achieve palliation of perineosacral pain in spite of rare overall long-term survival.     

Total cystectomies in the surgical treatment of rectal cancer with prior chemoradiation: analysis of postoperative morbidity and survival

BACKGROUND AND AIMS: Curative surgery for rectal cancer seldom requires urinary tract resections. The study investigated morbidity and survival following resection of rectum with total cystectomy following chemoradiation for primary rectal cancer. PATIENTS AND METHODS: 19 consecutive patients with primary nonresectable rectal cancer undergoing preoperative chemoradiation and operated on by a multidisciplinary team of surgeons. RESULTS: Morbidity was moderately low, and only five cases required surgical reintervention. No postoperative deaths were observed. Long-term survival in this group of patients compares well with the survival of patients with primarily nonresectable rectal cancer without the involvement of urinary bladder. CONCLUSION: Extended pelvic exenteration due to rectal cancer is relatively safe and in selected patients offers long-term survival and a chance of a cure. Involvement of the urinary bladder does not adversely affect outcome of rectal cancer treatment.     

Favorable short-term and long-term outcome after elective radical rectal cancer resection in patients 75 years of age or older

PURPOSE: Because the elderly population in Western countries is rapidly increasing, as is their life expectancy, studies aimed at determining the impact of major surgery for primary rectal cancer in this group are warranted. The purpose of this study was to compare perioperative morbidity and mortality and long-term disease-specific and overall survival in primary rectal cancer patients, older and younger than 75 years of age, subject to major pelvic surgery. METHODS: From September 1986 to December 1996, the Prospective Colorectal Service Database identified 1,120 consecutive patients who underwent major pelvic surgery for primary rectal cancer. Of these, 157 (15 percent) were 75 years of age or older and comprise the elderly group. From the remaining 963 patients younger than 75 years of age, a representative random sample of 174 was selected and constitutes the younger group. Data were obtained from computerized databases and confirmed via chart review and telephone interviews. RESULTS: Perioperative complications were observed in 53 (34 percent) elderly and 63 (36 percent;P=not significant) younger patients. Perioperative deaths occurred in two (1.3 percent) elderly and one (0.6 percent;P=not significant) younger patient. The median follow-up time was 48 months. Although the overall survival was lower in the elderly group (P=0.02; the 5-year overall survival rates were 51 and 66 percent), the disease-specific survival rate was similar in the two groups (P=0.75; the 5-year disease-specific survival rates were 69 and 71 percent). CONCLUSION: In select individuals 75 years of age or older, major pelvic surgery for primary rectal cancer can be done with perioperative morbidity and mortality rates comparable to those obtained in younger individuals, while achieving excellent disease-specific and overall long-term survival.     

Restorative and nonrestorative surgery for low rectal cancer after high-dose radiation: long-term oncologic and functional results

PURPOSE: This prospective, nonrandomized study evaluates, with a seven-year median follow-up, the morbidity and the functional and oncologic results of conservative surgery after high-dose radiation for cancer of the lower third of the rectum of patients who would otherwise have undergone abdominoperineal resection. METHODS: Between June 1990 and June 1996, 43 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 50 (range, 25-60) mm, and none of the tumors was fixed (15 percent T2N0, 53 percent T3N0, 32 percent T3N1). RESULTS: Postoperative mortality (2 percent) and morbidity (35 percent) were not increased by high-dose preoperative radiation. Conservative surgery was done in 30 patients (70 percent: 26 coloanal anastomoses and 4 low stapled anastomoses). After conservative surgery, long-term functional results showed 30 percent complete continence and 20 percent serious incontinence. Four patients had local recurrence as first development (13 percent). The seven-year overall survival rate was 53 percent, 62 percent after conservative surgery and 31 percent after abdominoperineal resection. The univariate analysis underscores the tumor response impact on long-term survival (pT<3 = 81 percent; pT3 = 35 percent; P = 0.0008). CONCLUSIONS: These long-term results confirm the feasibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective multicentric trial began in France in June 1996 to evaluate the reproducibility of these results.     

Restorative and Nonrestorative Surgery for Low Rectal Cancer After High-Dose Radiation

PURPOSE: This prospective, nonrandomized study evaluates, with a seven-year median follow-up, the morbidity and the functional and oncologic results of conservative surgery after high-dose radiation for cancer of the lower third of the rectum of patients who would otherwise have undergone abdominoperineal resection. METHODS: Between June 1990 and June 1996, 43 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 50 (range, 25–60) mm, and none of the tumors was fixed (15 percent T2N0, 53 percent T3N0, 32 percent T3N1). RESULTS: Postoperative mortality (2 percent) and morbidity (35 percent) were not increased by high-dose preoperative radiation. Conservative surgery was done in 30 patients (70 percent: 26 coloanal anastomoses and 4 low stapled anastomoses). After conservative surgery, long-term functional results showed 30 percent complete continence and 20 percent serious incontinence. Four patients had local recurrence as first development (13 percent). The seven-year overall survival rate was 53 percent, 62 percent after conservative surgery and 31 percent after abdominoperineal resection. The univariate analysis underscores the tumor response impact on long-term survival (pT<3 = 81 percent; pT3 = 35 percent; P = 0.0008). CONCLUSIONS: These long-term results confirm the feasibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective multicentric trial began in France in June 1996 to evaluate the reproducibility of these results.     

Surgical outcomes for colorectal cancer patients including the elderly

BACKGROUND/AIMS: The aim of this study was to compare the short- and long-term outcome of older and younger colorectal cancer patients resected for cure. METHODOLOGY: Three hundred and forty-six consecutive colorectal cancer patients who underwent some form of surgery were analyzed. One hundred and forty-four patients were < 65 years old (group 1), 151 patients were 65-79 years old (group 2), and 51 patients were 80 years or more (group 3). RESULTS: The overall perioperative mortality rate was 1.7% (n = 6). The median length of hospital stay was 19 days (range: 3-86 days). By univariate analysis, intraoperative bleeding (500 mL or more) (P = 0.009), duration of operations (240 min or more) (P = 0.03), and the presence of rectal cancer (P = 0.001), were strongly associated with higher incidence of postoperative complications. In multiple logistic regression analysis, only rectal cancer (P = 0.02) was significantly associated with serious postoperative complications. No age-related difference was noted concerning 5-year cancer-specific survival rates for patients with < 65, 65-79, and > or = 80 years who underwent surgery for cure (85%, 76%, and 69%, respectively) (P = 0.3). Using logistic regression analysis, tumor stage (P = 0.0001) and perioperative blood transfusions (500 mL or more) (P = 0.05) were strongly associated with outcome. CONCLUSIONS: Colorectal curative surgery for malignancy can be performed safely in the elderly with acceptable morbidity and mortality rates and long-term survival.     

Extended abdominoperineal resection with partial prostatectomy for T3 rectal cancer

BACKGROUND/AIMS: To describe and discuss extended abdominoperineal resection with partial prostatectomy using the ultrasonic harmonic scalpel as an alternative to total pelvic exenteration in lower rectal T3 cancer contiguous with the prostate. METHODOLOGY: Extended abdominoperineal resection with partial prostatectomy was performed in 4 patients with lower rectal clinical stage T3 cancer contiguous with the prostate using the ultrasonic harmonic scalpel. The ultrasonic harmonic scalpel permitted en bloc dissection of the rectum and the posterior part of the prostate, removing all tumor and disruption of the normal urinary stream. RESULTS: Blood loss ranged from 600 to 2500 mL. The final pathologic stage was T2 in 1, T3 in 2 and T4 in 1 patient, and the surgical margins were clear in all patients. Urethral injury occurred in 1 patient, and 2 patients had postoperative urinary dysfunction. No patients required a urinary stoma or suffered recurrence. CONCLUSIONS: Extended abdominoperineal resection with partial prostatectomy using the ultrasonic harmonic scalpel is an attractive alternative to total pelvic exenteration for patients with lower rectal T3 cancer contiguous with the prostate.     

Results from pelvic exenteration for locally advanced colorectal cancer with lymph node metastases

PURPOSE: We examined the survival benefit of pelvic exenteration for locally advanced colorectal cancer with lymph node metastases, because this issue remains controversial. METHODS: Medical records of 50 patients who underwent curative pelvic exenteration for colorectal cancer were reviewed retrospectively. Nodal metastases were examined by the clearing method in 29 patients and by the conventional manual method in 21 patients. RESULTS: Invasion to contiguous pelvic organs was present in 40 patients (80 percent) and absent in 10 patients (20 percent). Node metastases were present in 33 patients (66 percent). Operative morbidity and mortality rates were 22 percent (11 patients) and 6 percent (3 patients), respectively. Respective five-year survival rates were 60 and 80 percent in the groups with and without organ invasion (no significant difference). Five-year survival rates in patients with nodal metastases was 54.6 percent but was significantly higher, 82.4 percent, in patients without nodal metastases. Five-year survival in 28 patients with both organ invasion and nodal metastases was 53.6 percent. CONCLUSIONS: Long-term survival was afforded by pelvic exenteration for locally advanced colorectal cancer with nodal metastases.     

Pelvic exenterative procedures for locally advanced or recurrent colorectal carcinoma in a community hospital

Abstract. Background: We describe our experience with exenterative pelvic surgery for colorectal cancer in a small community hospital. Methods: We retrospectively evaluated 26 consecutive patients (14 women) with locally advanced (n=16) or recurrent (n=10) colorectal adenocarcinomas who underwent pelvic exenterations between August 1990 and December 2001 in our service. Results: Seventeen patients had posterior pelvic exenteration (PPE), eight had total pelvic exenteration (TPE) and one had TPE with internal hemipelvectomy. Major morbidity occurred in 12 patients (46%), causing 3 deaths (11%) in the immediate postoperative period. Fourteen of 23 patients who survived the immediate postoperative period have relapsed (61%). At a median follow-up of 42 months, the 5-year survival is 38%. Conclusion: Pelvic exenterative procedures can be offered to patients with bulky or recurrent colorectal carcinomas with adequate results and satisfactory palliation, even in a community setting.Presented in part at the 25th Meeting of the Italian Surgical Oncology Society, September 2001.     

Surgery for local pelvic recurrence after resection of rectal cancer

This retrospective study evaluated outcome with regard to procedure, local control, and survival after curative surgical resection with and without preoperative radiotherapy for local pelvic recurrence. A total of 58 consecutive patients with local pelvic recurrence of rectal cancer after previous curative resection for primary tumors were reviewed. Of these, 36 underwent both initial resection and follow-up in our department; the remaining 22 had initial surgery and follow-up elsewhere. Of the 58 patients 27 underwent curative re-resection, 9 had palliative resection, and 22 were treated by conservative therapy. Among the 27 patients with curative resection 17 received preoperative radiotherapy (40 Gy) plus surgery and 10 surgery only. No patients were lost to follow-up; median follow-up time was 36.3 months. The overall rate of curative resection was 46.6%: 55.6% in our own follow-up group and 31.8% in the others. With regard to surgical procedure, abdominoperineal resection (APR) with or without sacral resection was standard following previous low anterior resection, and total pelvic exenteration (TPE) with or without sacral resection was common following APR. There was a high incidence of morbidity (71.4%) after TPE. Re-recurrence was observed in 12 (44.4%) after curative re-resection. There was local re-recurrence in 6 (22.2%). The local re-recurrence rate was 11.8% (n = 2) with radiotherapy plus surgery, and 40.0% (n = 4) with surgery alone. The estimated 5-year survival following curative re-resection was 45.6% (61.2% with radiotherapy plus surgery, 29.6% with surgery alone). Both survival and local control with radiotherapy plus surgery tended to be better than with surgery alone. Thus, in selected patients pelvic local recurrence of rectal cancer can be re-resected curably by APR or TPE (with or without sacral resection) combined with preoperative radiotherapy. Accepted: 10 October 1997     

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: Long-term results

?

The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series.

Methods

Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study.

Results

Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %).

Conclusions

The study confirms the oncological safety of laparoscopic TME in a long follow-up period.     

Surgical Salvage of Recurrent Rectal Cancer After Transanal Excision

PURPOSE This study examines surgical salvage of locally recurrent rectal cancer following transanal excision of early tumors.METHODS Through retrospective review of a colorectal database we identified 50 patients who underwent attempted surgical salvage for local recurrence following initial transanal excision of T1 or T2 rectal cancer. Eight patients had resectable synchronous distant disease. Clinicopathologic variables were associated with extent of surgery required for salvage and outcome.RESULTS Salvage procedures included abdominoperineal resection (31), low anterior resection (11), total pelvic exenteration (4), and transanal excision (3). One patient had unresectable disease at exploration, requiring diverting ostomy. Of the 49 patients who underwent successful salvage, 27 (55 percent) required an extended pelvic dissection with en bloc resection of one or more of the following structures: pelvic sidewall and autonomic nerves (18); coccyx or portion of sacrum (6); prostate (5); seminal vesicle (5); bladder (4); portion of the vagina (3); ureter (2); ovary (1); and uterus (1). Complete pathologic resection (R0) was accomplished in 47 of 49 patients. Of the eight patients with distant and local recurrence, two underwent synchronous resection and six had delayed metastasectomy. With a median follow-up of 33 months, 29 patients had recurred or died of disease at the time of this analysis. Five-year disease-specific survival was 53 percent. Factors predictive of survival included evidence of any mucosal recurrence on endoscopy, low presalvage carcinoembryonic antigen, and absence of poor pathologic features (lymphovascular and perineural invasion). Patients who required an extended pelvic resection had a worse survival rate.CONCLUSION Pelvic recurrence following transanal excision of early rectal cancer is often locally advanced, requiring an extended pelvic dissection with en bloc resection of adjacent pelvic organs to achieve salvage. The long-term outcome in patients undergoing resection is less than expected, considering the early stage of their initial disease. When contemplating local excision for early rectal cancer, the risk of local recurrence, the extent and morbidity of surgery required for salvage, and the modest cure rate following salvage should be considered.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.Reprints are not available.     

Contemporary outcomes of total pelvic exenteration in the treatment of colorectal cancer

Purpose Total pelvic exenteration is performed infrequently in selected patients with locally advanced or recurrent colorectal cancer. We reviewed our contemporary experience with pelvic exenteration for colorectal cancer to identify selection criteria and prognostic factors for longterm survival. METHODS: Between 1991 and 2000, 55 patients (males, 29; median age, 62 years) undergoing total pelvic exenteration for colorectal cancer were identified from a prospective database. Clinicopathologic variables were evaluated as prognostic indicators of long-term survival by log-rank test and multivariate Cox regression. RESULTS: Indications for surgery were recurrent colorectal cancer in 71 percent and primary colorectal cancer in 29 percent. Of 39 patients with recurrent colorectal cancer, 85 percent had previous radiotherapy, and 64 percent had previous abdominoperineal resection. At the time of pelvic exenteration, 49 percent of patients received intraoperative radiation, and 20 percent required sacrectomy. Complete resection with negative margins was achieved in 73 percent. Perioperative mortality after pelvic exenteration was 5.5 percent, and complications included perineal wound infection (40 percent), pelvic abscess (20 percent), abdominal wound infection (18 percent), and cardiopulmonary events (18 percent). Median disease-specific survival for all patients was 48.9 (range, 3.2-105.6) months. Univariate analysis identified five factors associated with decreased survival: male gender, recurrent colorectal cancer, previous abdominoperineal resection, positive surgical margin, and administration of intraoperative radiation. On multivariate analysis, only previous abdominoperineal resection was an independent predictor of unfavorable outcome (P < 0.04). CONCLUSIONS: Total pelvic exenteration can be performed safely in highly selected patients with colorectal cancer and can result in significantly prolonged survival. Less satisfactory outcomes are observed in patients whose indication for pelvic exenteration is recurrent colorectal cancer after abdominoperineal resection. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 7, 2002.     

Neoadjuvant external beam radiation and proctectomy for adenocarcinoma of the rectum

PURPOSE: The aim of this study was to determine the survival rate, local failure, and perioperative morbidity in patients with adenocarcinoma of the rectum undergoing curative proctectomy who were felt to have transmural disease on preoperative assessment. Eighty-nine percent of these patients were treated with preoperative external beam radiotherapy. METHODS: The records of 191 consecutive patients undergoing abdominal surgical procedures for primary treatment of rectal cancer were reviewed. The product-limit method (Kaplan-Meier) was used to analyze survival rate and tumor recurrence. RESULTS: One patient was excluded from survival analysis because of incomplete record of tumor stage. The study population comprised 109 males and 81 females, median age 64 (range, 33–91) years. Curative resection was performed in 152 of these 190 patients (80 percent), including low anterior resection with coloproctostomy or coloanal anastomosis (n=103), abdominoperineal resection (n=44), Hartmann's procedure (n = 4), and pelvic exenteration (n=1). Mean follow-up of patients undergoing curative resection was 96±48 months. Palliative procedures were performed in 38 of 190 patients (20 percent). Perioperative mortality was 0.5 percent (1/190). Complications occurred in 64 patients (34 percent). The anastomotic leak rate was 4 percent (5/128). Disease-free five-year survival rate by pathologic stage was as follows: Stage I, 90 percent; Stage II, 85 percent; Stage III, 54 percent; Stage IV, 0 percent; and no residual tumor, 90 percent. Of the 152 patients treated with curative resection, disease-free survival rate was 80 percent at five years. Preoperative external beam radiation was administered to 135 of these 152 patients (89 percent). Tumor recurred in 32 of 152 patients (21 percent) treated with curative resection. The predominant pattern of recurrence was distant failure only. Kaplan-Meier overall local recurrence (local and local plus distant) at five years was 6.6 percent. The local recurrence rate paralleled tumor stage: Stage I, 0 percent; Stage II, 6 percent; Stage III, 20 percent; and no residual tumor, 0 percent. CONCLUSION: Preoperative external beam radiotherapy and attention to mesorectal dissection can achieve low local recurrence and excellent long-term survival rate in patients with adenocarcinoma of the rectum. Moreover, these goals can be obtained with low morbidity and mortality.Dr. Ogunbiyi was supported in part by grants from the Ronald Raven Traveling Fellowship of the British Association of Surgical Oncology, the American Society of Colon and Rectal Surgeons Research Foundation International Traveling Fellowship, and the Royal College of Surgeons of England Ethicon Foundation Traveling Fellowship.Presented at the meeting of the Missouri Chapter of the American College of Surgeons, Lake of the Ozarks, Missouri, June 18 to 19, 1999.     

A Retrospective Analysis of Ultralow Anterior Resection vs. Abdomino-Perineal Resection for Lower Rectal Cancer

Background/Aims: The aim of this study was to compare the oncological outcome of ultralow anterior resection (ULAR) and abdominoperineal resection (APR) for lower rectal cancer. Methodology: Medical records of 276 patients with lower rectal cancer of whom 140 underwent ULAR and 136 underwent APR were included in a retrospective comparative study. Clinicopathological parameters, overall survival and tumor relapse and prognostic factors were analyzed retrospectively. Results: There was no postoperative mortality in either group. Medical and surgical morbidity, especially pelvic abscess formation were similar in the two groups. The operation time was longer in the APR group (p<0.001). The hospital stay was shorter in the ULAR group (p=0.003). The 5 year overall and disease-free survival rates were 60.5% and 51.1%. There was no difference of overall and disease-free survival (p>0.05), between ULAR and APR surgery at 5 years. Patients who underwent ULAR showed more total recurrence (34.3% vs. 22.1%, p=0.031) and more local recurrence (20.7% vs. 8.8%, p=0.01) but showed no difference in distant recurrence (13.6% vs. 13.2%, p=0.92). Conclusions: Ultralow anterior resection and abdominoperineal resection have similar long-term outcome in lower rectal cancer. In tumor local relapse, APR is more effective than ULAR, but in distant metastasis, it not better than ULAR.     

Pancreaticoduodenectomy for locally advanced gastric cancer

BACKGROUND/AIMS: This study was conducted to evaluate the therapeutic efficacy of pancreaticoduodenectomy (PD) in the patients with locally advanced gastric cancer. METHODOLOGY: 25 gastric cancer patients who underwent PD with gastrectomy were analyzed. The indications of PD were 1) suspicion of direct invasion to the pancreas head (n = 15), 2) invasion to duodenal second portion (n = 6), 3) both pancreatic and duodenal invasion (n = 3), and 4) conglomerated lymph node enlargement around the pancreas head (n = 1). RESULTS: Mean operation time was 349.5 (+/- 86.5) minutes and mean amount of RBC transfusion was 3.4 (+/- 2.1) pints. Postoperative complications were encountered in 8 patients (32%), but re-operation was required only in 2 cases. No postoperative 30-day mortality occurred after PD. Overall the median survival was 16.5 months with a 5-year survival rate of 15.8%. Two patients with T2bN0M0 and T2bN1M0 stages were still alive for 11.5 years and 5.7 years without any evidence of cancer recurrence. CONCLUSIONS: Considering the acceptable postoperative morbidity rate and the long-term survivors in selected cases, PD could be considered as one of the therapeutic options for locally advanced gastric cancer.     

T-level downstaging and complete pathologic response after preoperative chemoradiation for advanced rectal cancer result in decreased recurrence and improved disease-free survival

PURPOSE: Preoperative chemoradiation therapy is used widely in the treatment of rectal cancer. The predictive value of response to neoadjuvant remains uncertain. We retrospectively evaluated the impact of response to preoperative and, specifically, of T-level downstaging, nodal downstaging, and complete pathologic response after chemoradiation therapy on oncologic outcome of patients with locally advanced rectal cancer. METHODS: There were 88 patients with ultrasound Stage T3/T4 midrectal (n = 37) and low rectal (n = 51) cancers (63 males; mean age 62.6 years). All patients were treated by preoperative 5-fluorouracil-based chemotherapy and pelvic radiation followed by surgical resection in six weeks or longer (56 sphincter-preserving resections). RESULTS: T-level downstaging after neoadjuvant treatment was demonstrated in 36 (41 percent) of 88 patients, and complete pathologic response was observed in 16 (18 percent) of the 88. Of the 42 patients with ultrasound-positive nodes, 27 had no evidence of nodal involvement on pathologic evaluation (64 percent). The overall response rate (T-level downstaging or nodal downstaging) was 51 percent. At a median follow-up of 33 months, 86.4 percent of patients were alive. The overall recurrence rate was 10.2 percent (three patients had local and six had metastatic recurrences). Patients with T-level downstaging and complete pathologic response were characterized by significantly better disease-free survival (P = 0.03, P = 0.04) and better overall survival (P = 0.07, P = 0.08), according to Wilcoxons test comparing Kaplan-Meier survival curves. None of the patients with complete pathologic response developed recurrence or died during the follow-up period. CONCLUSION: T-level downstaging and complete pathologic response after preoperative chemoradiation therapy followed by definitive surgical resection for advanced rectal cancer resulted in decreased recurrence and improved disease-free survival. Advanced rectal cancers that undergo T-level downstaging and complete pathologic response after chemoradiation therapy may represent subgroups that are characterized by better biologic behavior.