Quality of Life Among Five-Year Survivors After Treatment for Very Low Rectal Cancer With or Without a Permanent Abdominal Stoma

Background Low rectal cancers situated less than 5 cm from the anal margin are still usually treated with abdomino-perineal excision (APE). Our aim is to compare the quality of life (QOL) of five-year survivors treated for low or very low rectal cancer with an advanced/complex coloanal procedure with the QOL of patients submitted to a standard APE with a definitive abdominal stoma. Methods Sixty-two patients, operated on radically for low or very low rectal cancer, who came for their fifth year follow-up visit and were free from cancer, were studied. Thirty patients (group 1) had an APE with permanent abdominal stoma. Thirty-two patients (group 2) had undergone a radical advanced and complex procedure to avoid the abdominal stoma. The patients received the European Organisation for the Research and Treatment of Cancer (EORTC) QOL-30 generic and the CR38 colorectal cancer QOL questionnaires with the recommendation to return the questionnaire to the hospital. The Mann–Whitney U-test and χ ² Fisher test were employed for statistical analysis. Results All questionnaires were returned. Patients without a terminal abdominal stoma had a better score in six categories of the QOL 30 and in two categories of the CR38. No differences were observed in the other variables examined. Conclusions After five years, cancer-free patients operated on for low or very low rectal cancer have a better QOL if a definitive terminal abdominal stoma was avoided. The paper has been partially presented at the 9^th International Meeting of Coloproctology, Stresa, Italy, March 27–29, 2006     

Total Rectal Resection and Complete Mesorectum Excision Followed by Coloendoanal Anastomosis as the Optimal Treatment for Low Rectal Cancer: The Experience of the National Cancer Institute of Milano

Background: At present, abdominoperineal resection remains the most diffuse method of treatment of very low rectal cancer. Today, we can avoid this method in some patients by using a sphincter-saving procedure.Methods: From March 1990 to January 1999, 273 consecutive total rectal resections and coloendoanal anastomoses were performed at our Institute; this study concerns 141 consecutive patients treated for a primary adenocarcinoma of the distal rectum, from 3.5 to 8 cm from the anal verge. Patient stratification, based on definitive pathological report, was 31 Dukes stage A (T2N0), 44 stage B (T3N0), and 66 stage C (T2N+–T3N+).Results: Overall recurrence rate was 9.2%; postoperative morbidity attributable to the procedure was low. A perfect continence was documented in 61% of cases. The only pathological factor related to local recurrence rate is peritumoral lymphocytic reaction inside and around the tumor (P = .0005 and .031) independently from the number of metastatic lymph nodes, depth of fatty tissue infiltration, and lymphatic and venous neoplastic emboli. The minimum follow-up time is 12 months.Conclusions: Our data, in accordance with other authors, seem to highlight the relevant role that a well-practiced surgery, together with accurate information on the spreading of this disease, has in achieving an optimal local control of cancer.Presented at the 52nd Annual Meeting of Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Ultra-Low Anterior Resection with Coloanal Anastomosis for Recurrent Rectal Prolapse in a Young Woman with Colitis Cystica Profunda

This case demonstrates the successful treatment of a young female patient with colitis cystica profunda causing rectal prolapse, after primary treatment with a Delorme procedure had failed. An ultra-low anterior resection with a temporary defunctioning ileostomy was carried out with good postoperative results. This case illustrates the possibility of carrying out sphincter preserving surgery rather than an abdominoperineal resection in the treatment of this condition, which may be preferable for patients.     

Anterior Resection of Rectal Cancer Without Bowel Preparation and Diverting Stoma

Purpose Since the introduction of total mesorectal excision (TME) as the standard operation technique for rectal cancer, anastomotic leakage percentages of up to 18% have been reported. To prevent such leakage, the use of mechanical bowel preparation and also the construction of a diverting ileostoma or colostomy have been standard procedures for years. In our institute, however, all patients undergoing colorectal surgery are operated upon without these measures. The present study was undertaken to investigate the results of this strategy in terms of the occurrence of postoperative anastomotic leakage.Methods All patients who underwent an elective (low) anterior resection between January 1996 and December 2001 (n = 144) entered the study. The clinical and pathological records of these patients were reviewed retrospectively. The exclusion criteria were patients with fixed rectal carcinoma who received preoperative radiotherapy and/or a stoma only at operation, emergency operations, abdominoperoneal resections, and Hartmann’s procedures.Results Anastomotic leakage occurred in 7 out of 144 patients (4.9%). There was a trend toward a higher leakage frequency in men, in patients with a distal anastomosis, in patients with a stapled anastomosis, and in patients with a T3–T4 tumor or with positive lymph nodes. None of these factors, however, had a significant prognostic value based on a univariate or multivariate analysis. Those who died after leakage tended to be older than those who did not (P < 0.05).Conclusion A (low) anterior resection can be performed safely without mechanical bowel preparation or a diverting stoma, and results in an anastomotic leakage percentage of less than 5%. Appropriate selection of patients may be important, but none of the investigated patient- or tumor-related factors could be identified as decisive.     

经肛门拖出吻合器吻合法在腹腔镜直肠癌根治术中的应用

目的 探讨经肛门拖出吻合器吻合在腹腔镜直肠癌根治术中应用的可行性及临床疗效。方法 2010年6月～2013年1月,采用腹腔镜辅助经肛门拖出吻合器吻合法治疗30例中低位直肠癌。22例≤T2期,8例T3期,均为N0,M0。电子结肠镜检查显示肿瘤下缘距肛缘的距离4.0～10.0cm,（7.6±1.5）cm;肿瘤直径2～6cm,（3.8±1.3）cm。先在腹腔镜下进行直肠全系膜切除,于耻骨联合上做下腹部正中辅助切口,直视下切断近端结肠,经肛门拖出切除直肠标本,应用双荷包、单吻合器技术,以国产管型消化道吻合器（31.5mm或28.5mm）行结一直肠端端吻合。结果 30例手术均顺利完成。手术时间170～280min,（216.3±25.9）min。术中出血量50～700ml,（273.3±160.1）ml。术后肛门排气时间1～4d,（2.5±0.8）d。术后住院时间8～30d,（12.2±4.2）d。肠管远端切缘距肿瘤的距离2.0～6.0cm,（3.9±0.9）cm。远近切缘均未见癌残留。术后发生吻合口漏1例（3.3％）,腹腔积液并感染1例（3.3％）,均经非手术治疗治愈,无腹腔内出血、肠梗阻、吻合口出血等并发症。随访6～24个月,（11.8±3.9）月,术后3个月大便次数1～5次／d;1例吻合口瘢痕收缩狭窄,排便困难,予以扩肛等处理后好转;1例术后16个月局部肿瘤复发,行腹一会阴联合直肠癌根治术（Miles手术）。结论 经肛门拖出吻合器吻合联合腹腔镜手术治疗中低位直肠癌安全可行,值得推广应用。     

Laparoscopic-Assisted Versus Open Abdominoperineal Resection for Low Rectal Cancer: A Prospective Randomized Trial

Background  Laparoscopic resection of colonic cancer has been shown to improve postoperative recovery without jeopardizing tumor clearance and survival, but information on low rectal cancer is scarce. The aim of this randomized trial was to compare postoperative recovery between laparoscopic-assisted versus open abdominoperineal resection (APR) in patients with low rectal cancer. Recurrence and survival data were also recorded and compared between the two groups. Methods  Between September 1994 and February 2005, 99 patients with low rectal cancer were randomized to receive either laparoscopic-assisted (51 patients) or conventional open (48 patients) APR. The median follow-up time of living patients was about 90 months for both groups. The primary and secondary endpoints of the study were postoperative recovery and survival, respectively. Data were analyzed by intention-to-treat principle. Results  The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with earlier return of bowel function (P < .001) and mobilization (P = .005), and less analgesic requirement (P = .007). This was at the expense of longer operative time and higher direct cost. There were no differences in morbidity and operative mortality rates between the two groups. After curative resection, the probabilities of survival at 5 years of the laparoscopic-assisted and open groups were 75.2% and 76.5% respectively (P = .20). The respective probabilities of being disease-free were 78.1% and 73.6% (P = .55). Conclusions  Laparoscopic-assisted APR improves postoperative recovery and seemingly does not jeopardize survival when compared with open surgery for low rectal cancer. A larger sample size is needed to fully assess oncological outcomes. Part of this paper has been presented as free paper in the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, October 18–21, 2006, Seoul, Korea. An erratum to this article can be found at     

A Meta-Analysis of Quality of Life for Abdominoperineal Excision of Rectum versus Anterior Resection for Rectal Cancer

Background Avoiding a permanent stoma following rectal cancer excision is believed to improve quality of life (QoL), but evidence from comparative studies is contradictory. The aim of this study was to compare QoL following abdominoperineal excision of rectum (APER) with that after anterior resection (AR) in patients with rectal cancer. Methods A literature search was performed to identify studies published between 1966 and 2006 comparing values of QoL following APER and AR. Random-effect meta-analysis was used to combine the data. Sensitivity analyses were performed for larger studies, those of higher quality and those using self-administered QoL questionnaires. Results The outcomes for 1,443 patients from 11 studies, of whom 486 (33%) underwent APER, were included. QoL assessments were made at periods of up to 2 years following surgery. There was no significant difference in global health scores between APER and AR. Vitality (WMD −9.82; 95% CI −27.01, −2.04, P = 0.01) and sexual function (WMD −2.73; 95% CI −4.93, −0.64, P = 0.01) were improved in the AR patients. Patients with low AR had improved physical function scores in comparison with APER patients (WMD −4.67; 95% CI −9.10, −0.23; P = 0.004). Cognitive (WMD 3.57; 95% CI 1.41, 5.73; P < 0.001) and emotional function scores (WMD 3.51; 95% CI 1.40, 5.62; P < 0.001) were higher for APER patients. Conclusion Overall, when comparing APER with AR, we identified no differences in general QoL following the procedures. Individualisation of care for rectal cancer patients is essential, but a policy of avoidance of APER cannot currently be justified on the grounds of QoL alone.     

直肠癌前切除术后吻合口复发的原因分析(附91例报告)

目的：探讨直肠癌前切除(Dixon术式)术后吻合口复发的原因及防治对策。方法：回顾性分析我院1985～1996年间所收治的91例直肠癌前切除术后吻合口复发病例的资料。结果：对前切除术后吻合口复发患者，再次行根治性Miles术式47例，姑息性切除27例，单纯探查11例，余6例放弃手术。其中行根治性Miles术的患者术后获随访32例，其1、3、5年生存率分别为93％、77％和45％。结论：盲目扩大前切除术适应证，将增加术后吻合口复发率，直肠指检、纤维结肠镜加活检是诊断吻合口复发的主要手段，对吻合口复发应积极争取行再次根治性切除。     

Institutional Commitment to Rectal Cancer Screening Results in Earlier-Stage Cancers on Diagnosis

Background: The Veterans Administration hospitals underwent an institutional directive in 1998 to meet a colorectal cancer screening (CRCS) standard. This intervention should result in an increase in the hospitals screening rate and percentage of early-stage rectal cancers diagnosed.Methods: A retrospective review, from 1991 to 2002, of our institutions pathology and cancer registry databases for rectal cancers. CRCS data were obtained from the Veterans Administration Prevention Disease Index. Cancer stage at diagnosis was compared before and after the directive and was compared with the National Cancer Data Base and the Surveillance, Epidemiology, and End Results data.Results: The rate of CRCS was 55% in 1998 and increased to 75% in 2003. During the 11 years studied, a total of 147 rectal cancers were diagnosed. After the Veterans Administration directive, there was a significant increase in stage 0 cancers (P < .02) and an overall migration to earlier-stage cancers. Our Veterans Administration hospital had a significantly greater percentage of stage 0 cancers both before (P < .007) and after the directive (P < .00) and had fewer stage 3 cancers after the directive (P < .03) compared with National Cancer Data Base data. Compared with Surveillance, Epidemiology, and End Results data, the Palo Alto Veterans Affairs Health Care System had more local disease (P < .03) and less regional disease (P < .006).Conclusions: These data suggest that a monitored institutional directive may significantly increase early detection of rectal cancers. This should result in a greater survival rate and lower local recurrence rate, because survival is predicated on stage at presentation. This may serve as a model for other health-care systems.     

Defunctioning Stoma and Anastomotic Leak Rate after Total Mesorectal Excision with Coloanal Anastomosis in the Context of PROCARE

Background : Anastomotic leakage (AL) after total mesorectal excision is a major adverse event. Construction of a defunctioning stoma (DS) reduces the morbidity of AL. This study aims to illustrate the AL rate and its related morbidity with and without primary stoma formation in the context of a Belgian project, PROCARE. Methods : Between January 2006 and March 2011, 1912 patients who underwent elective TME with colo-anal anastomosis for invasive rectal adenocarcinoma up to 15 cm above the anal verge were registered. A primary DS was constructed in 1183 patients (62%). Early clinical AL rate, AL-related re-operation rate, length of stay (LoS), inhospital mortality were analysed.

Results : In patients without leak, mortality was 1.1% and the mean LoS was 14.7 days. AL occurred in 6.5%, varying from 0%-25% between participating centres. In patients with AL, mortality was 4.8% (p < 0.001). In the presence of a primary DS, AL rate was 4.3%, requiring re-operation under narcosis in 78% with no mortality, resulting in a mean LoS of 30.4 days. In the absence of a primary DS, AL rate was 10.2%, requiring re-operation under narcosis in 93% with a mortality of 8.1% and a mean LoS of 33.4 days. Analysis per centre showed a weak relation between percentage of DS construction and AL rate.

Conclusion : Construction of a primary DS significantly reduced the incidence of early AL, re-operation rate, and mortality. Although technical aspects of colo-anal anastomosis are of paramount importance, construction of a DS at primary surgery has to be considered by those teams with high early AL rate and/or high AL related mortality.     

腹腔镜下直肠癌全系膜切除拖出式吻合8例报告

目的探讨腹腔镜下直肠癌全系膜切除术(total mesorectal excision,TME)的优势及拖出式吻合的使用价值。方法2005年11月~2006年12月对8例直肠癌行腹腔镜下直肠癌TME,经肛门拖出切除并手工吻合。结果8例均完全在腹腔镜下完成全系膜游离后拖出肛门外切除并手工吻合,无辅助切口。手术时间180~300min,平均220min。8例随访8~18个月,平均13个月,未发现穿刺口种植和局部复发。结论腹腔镜下完成全系膜游离,清晰完整,拖出肛门外切除、吻合直观、简便、经济。     

腹腔镜辅助腹会阴切除与开腹手术的对比研究

目的 :前瞻性评估腹腔镜辅助腹会阴切除和开腹手术这两种技术的优劣性 ,并探讨腹腔镜辅助腹会阴切除的可行性和安全性。方法 :将根治切除的 4 1例直肠癌患者 ,分为腹腔镜组 2 1例和开腹组 2 0例 ,观察两组肿瘤手术切除、并发症、术后恢复和肿瘤复发情况。结果 :两组的手术时间、出血量差异无统计意义 (t=0 .6 0 6 ,P =0 .5 4 8和 t=0 .0 77,P =0 .939)。切除标本的长度、全直肠系膜完整数、肠系膜下动脉高位结扎数、淋巴结切除数等肿瘤学根治方面差异亦无统计学意义 (均 P>0 .0 5 )。腹腔镜组止痛药使用少于开腹组 (χ2 =4 .0 84 ,P =0 .0 4 3) ,腹腔镜组的造口排气时间、起床活动时间均短于开腹组 (t=2 .4 5 5 ,P =0 .0 1 9和 t=2 .6 37,P =0 .0 1 2 ) ,住院时间两组无统计学差异 (t=0 .6 81 ,P =0 .5 0 0 )。两组的并发症发生率大致相同 (均 P >0 .0 5 )。两组随访时间分别为 2 4个月 (6～ 5 8个月 )和 36个月 (7～ 6 6个月 ) (P =0 .1 6 3) ,两组肿瘤早期复发率类似 (P =1 .0 0 0 )。结论 :提示腹腔镜腹会阴切除在技术上不仅是可行的 ,也是安全的     

Prospective Evaluation of Quality of Life of Patients Receiving Either Abdominoperineal Resection or Sphincter-Preserving Procedure for Rectal Cancer

Background Study results on quality of life (QoL) between patients receiving an anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer vary greatly. A main reason is grounded in unequal methodology. The aims of this study were to assess differences in perceived QoL over time among patients treated with AR or APR with a recommended study design and methodology.Methods In a prospective study, the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and a tumor-specific module were administered to patients with rectal cancer before surgery, at discharge, and 3, 6, and 12 months after the operation. Comparisons were made between patients receiving an AR and those receiving an APR.Results Two hundred forty-nine patients were included; 46 patients received an APR and 203 an AR. QoL data were available for 212 patients, of which 112 were female and 100 male. No differences in the distribution of age, sex, or tumor stage were observed between groups. EORTC function scales showed no significant differences, including body image scales, between patients receiving an AR and those receiving an APR. In symptom scores, AR patients had more difficulty with diarrhea and constipation, whereas patients with APR experienced more impaired sexuality and pain in the anoperineal region. At discharge, patients receiving an AR were more confident about their future.Conclusions QoL in patients receiving an AR and those receiving an APR is not different. Although patients with APR experience more impaired sexuality, patients receiving an AR experience decreases in QoL because of impaired bowel function.     

Robotic Coloanal Anastomosis with or without Intersphincteric Resection for Low Rectal Cancer: Starting with the Perianal Approach Followed by Robotic Procedure

Background  

Coloanal anastomosis (CAA)/intersphincteric resection (ISR) is a promising method of sphincter-preserving surgery for very low rectal cancer. Recently, a robotic system has been attempted in CAA/ISR. By means of a robotic system, an excellent stereoscopic view may be obtained with high illumination, and adequate traction and countertraction can be easily performed in a narrow pelvis using the Endowrist function. During robotic CAA/ISR, although the robotic system is necessary to perform pelvic dissection that comes before the perianal approach, the huge robotic arms located in the low abdominal region could interfere with comfortable perianal dissection for the surgeon. Therefore, the robotic system has to be withdrawn and then set up again above the patient’s abdomen, which is time-consuming. Moreover, this process also makes it difficult to maintain the aseptic circumstance of the robotic system. To address this problem, it is necessary to change the sequence of the procedure.     

肛外斜形吻合保肛术治疗中低位直肠癌的临床应用(附17例报告)

目的：为提高中低位直肠癌保肛术结直肠吻合疗效，减少合并症，以提高患者术后的生活质量。方法：采用直肠经腹腔、肛管拖出式切除，将结肠近端与直肠残端呈斜面吻合的保肛术治疗17例中低位直肠癌患者。结果：术后效果理想，保肛率100％，排便功能很快恢复，吻合口狭窄率及吻合口瘘发生率明显减少。结论：该术式操作简单，疗效满意，易于推广。     

结肠成型袋对改善中低位直肠癌术后排便功能的作用

目的：探讨结肠成型袋对改善中低位直肠癌术后排便功能的作用。方法：将62例中下段直肠癌患者根据消化道重建方法分为两组,32例行传统的结肠断端与直肠肛管直接端端吻合（CAA组）,30例断端结肠先行结肠成型术制成结肠贮袋再与直肠肛管行端端吻合（TCP组）。分别于术后1、3、6、9个月和1年、1年半对排便功能进行评估,比较两组的手术并发症和排便功能指标。结果：CAA组和TCP组平均大便次数：术后6个月分别为5次和2次（P〈0.001）,术后1年分别为3次和1次（P〈0.05）,术后1年半均为2次（P〉0.05）。TCP组定性排便控制能力近期优于CAA组。结论：中下段直肠癌低位前切除结肠成型术后直肠肛管吻合不增加手术并发症,在术后第1年内有明显改善排便功能的作用。     

Pre-Operative Radiochemotherapy for Rectal Cancer.

Purpose: The aim of the study was to find out whether pre-operative radiochemotherapy had any survival advantage over postoperative radiochemotherapy for rectal carcinoma patients without distant metastasis or peritoneal carcinomatosis.

Material and methods: Between January 1998 and December 2003, 51 rectal carcinoma patients without distant metastasis or peritoneal carcinomatosis were randomly divided into pre-operative (PRE) and postoperative (POST) radiochemotherapy groups. Twenty-six were assigned to the PRE group and were operated on 5 to 8 weeks after the completion of radiotherapy. The other 25 patients were operated on immediately and received radiotherapy post-operatively 2 to 4 weeks after surgery. The patients were followed up for between 4 to 51 months. Results: In the PRE group the rates of disease-free survival were 92%, 70%, 56% and 56% at the end of the 1^st, 2^nd, 3^rd and 4^th years, respectively. In the POST group those percentages were 83%, 68%, 51% and 51% at the 1^st, 2^nd, 3^rd and 4^th years, respectively (p = 0.707). One-year and 4-year overall survival rates in the PRE group were 100% and 86% respectively and 100% and 60% in the POST group (p = 0.520).

Conclusion: No statistical difference was found between the survival rates of the rectal carcinoma patients receiving radiotherapy either pre-operatively or postoperatively. However, the disease-free survival rates of the PRE group were higher than the POST group’s during each year and overall survival rates were higher after the third and fourth years. We conclude that pre-operative radiotherapy is at least as effective as postoperative radiotherapy.     

低位直肠癌保肛术无预防性造口的意义

目的探讨低位直肠癌保肛术中不行预防性造口的意义。方法57例低位直肠癌前切除术中,32例未行预防性回肠末端造口(A组),吻合后行漏气实验以确认缝合严密,并内置肛管,顶端达吻合口上方3~5 cm。25例行预防性造口(B组)。结果A组术后发生吻合口漏1例(3.1%),吻合口出血2例(6.2%),切口感染1例(3.1%),肠梗阻2例(6.2%);B组发生吻合口漏1例(4.0%),吻合口出血3例(12.0%),废用性肠炎19例(76.0%),切口感染8例(32.0%),肠梗阻4例(16.0%)。结论应用合适的技术及围手术期处理方法进行无预防性造口的低位直肠癌保肛术效果好,克服了许多预防性造口的并发症。     

Modified Double-Stapling Technique in Low Anterior Resection for Lower Rectal Carcinoma

Purpose The original double-stapling technique (DST) using a standard linear stapler horizontally can be difficult in patients with a narrow pelvis or an ultralow anastomosis. We review our experience of performing a modified DST (IO-DST) with vertical division of the rectum achieved using an endostapler. Methods We retrospectively studied the clinical outcomes of 90 patients who underwent low anterior resection (LAR) for lower rectal carcinoma. Low anterior resection was performed with IO-DST in 34 patients (IO-DST group), with the single-stapling technique (SST) in 47 (SST group), and with per anal anastomosis (PAA) in 9 (PAA group). Results The distances from the anal verge to the tumor and to the anastomosis were significantly shorter in the IO-DST group than in the SST group (5.8 cm, 4.0 cm vs 7.0 cm, 5.0 cm, respectively), whereas it was equivalent in the IO-DST and PAA groups (5.0 cm, 4.0 cm). Blood loss was less in the IO-DST group than in the SST and PAA groups (400 ml vs 578 ml and 950 ml, respectively). The operative time was shorter in the IO-DST group than in the PAA group (281 min vs 327 min, respectively). There were no significant differences in the length of the distal surgical margin among the three groups. The IO-DST group patients suffered less bowel frequency than the SST group patients 1 month after surgery (2.5 times/day vs 4.0 times/day, respectively) and less than the PAA group patients more than 1 year after surgery (2.0 times/day vs 3.5 times/day, respectively). There were no significant differences in the incidence of complications or local recurrence among the three groups. Conclusions IO-DST is a feasible and safe procedure for performing low anastomosis, which results in less bowel frequency after LAR for lower rectal carcinoma.     

腹腔镜直肠癌手术的手术方式选择探讨

目的:探讨腹腔镜直肠癌根治术的手术方式选择。方法:回顾性分析2002年11月至2005年11月间施行的88例腹腔镜直肠癌手术,包括中转率、手术要点和并发症率等。结果:本组中转开腹7例(8.0%)。88例中经腹腔镜前切除吻合40例,经腹腔镜肛管根治性切除乙状结肠肛管吻合14例,经腹腔镜腹会阴联合切除术33例,1例因合并3度会阴撕裂伤行经腹腔镜Hartmann手术。无术中并发症及手术死亡,术后并发症8例,5例为出血并发症。结论:腹腔镜直肠癌手术安全、有效,但应个体化选择手术方式。