T3N0 rectal cancer: Results following sharp mesorectal excision and no adjuvant therapy

Adjuvant chemoradiation therapy following resection of T3N0 rectal cancer is recommended in order to reduce the incidence of local recurrence and improve survival. However, recent experience with rectal cancer resection utilizing sharp dissection and total mesorectal excision has resulted in a reduction in local recurrence rates to as low as 5% without adjuvant treatment. The purpose of this study was to determine if rectal cancer resection utilizing sharp mesorectal excision alone is adequate treatment for local control of T3N0 rectal cancer. Between July 1986 and December 1993, 95 patients with T3N0M0 rectal cancer underwent resection with sharp mesorectal excision and did not receive any adjuvant therapy. Various prognostic factors were analyzed for their association with local recurrence and survival. Seventy-nine patients had a low anterior resection, 10 of whom had a coloanal anastomosis, and 16 had an abdominoperineal resection. The median follow-up was 53.3 months. Six patients had local recurrence, 12 had distant recurrence, and three had local and distant recurrences. The overall local recurrence rate was 9% crude and 12% 5-year actuarial. The overall crude recurrence rate was 22%. The 5-year disease-specific survival rate was 86.6% with an overall survival of 75%. Postoperative complications occurred in 18 patients (19%). Five patients (6%) had a documented anastomotic leak. Perioperative mortality was 3%. No technical factors, including type of resection (low anterior vs. abdominoperineal), location of tumor, or extent of resection margin, were significant for determining local recurrence. The only histopathologic marker significant for determining local recurrence was lymphatic invasion (P <0.04). Sharp mesorectal excision with low anterior resection or abdominoperineal resection for T3N0M0 rectal cancer results in a local recurrence rate of less than 10% without the use of adjuvant therapy. Therefore, in select patients with T3N0M0 rectal cancer, the standard use of adjuvant therapy for local control may not be justified. Presented at the Thirty-Ninth Annual Meeting of The Society of Surgery for the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Local recurrence following surgical treatment for carcinoma of the lower rectum

BACKGROUND: The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS: During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS: The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION: The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).     

Radiological findings do not support lateral residual tumour as a major cause of local recurrence of rectal cancer

BACKGROUND: The aim of this study was to determine the sites of local recurrence following radical (R0) total mesorectal excision (TME) for rectal cancer in an effort to elucidate the reasons for recurrence. METHODS: Thirty-seven patients with recurrence following curative resection for rectal cancer were identified from a population of 880 patients operated on by surgeons trained in the TME procedure. Two radiologists independently examined 33 available computed tomograms and magnetic resonance images taken when the recurrence was detected. RESULTS: Twenty-nine of the 33 recurrences were found in the lower two-thirds of the pelvis. Two recurrent tumours appeared to originate from lateral pelvic lymph nodes. Evidence of residual mesorectal fat was identified in 15 patients. Fourteen of the recurrent tumours originated from primary tumours in the upper rectum; all of these tumours recurred at the anastomosis and 12 of the 14 patients had evidence of residual mesorectal fat. CONCLUSION: Lateral pelvic lymph node metastases are not a major cause of local recurrence after TME. Partial mesorectal excision may be associated with an increased risk of local recurrence from tumours in the upper rectum.     

Anastomotic leakage after anterior resection for rectal cancer: risk factors

Objective  The study aimed to identify risk factors for clinical anastomotic leakage (AL) after anterior resection for rectal cancer in a consecutive national cohort.
Method  All patients with an initial first diagnosis of colorectal adenocarcinoma were prospectively registered in a national database. The register included 1495 patients who had had a curative anterior resection between May 2001 and December 2004. The association of a number of patient- and procedure-related factors with clinical AL after anterior resection was analysed in a cohort design.
Results  Anastomotic leakages occurred in 163 (11%) patients. In a multivariate analysis, the risk of AL was significantly increased in patients with tumours located below 10 cm from the anal verge if no faecal diversion was undertaken (OR 5.37 5 cm (tumour level from anal verge), 95% CI 2.10–13.7, OR 3.57 7 cm, CI 1.81–7.07 and OR 1.96 10 cm, CI 1.22–3.10), in male patients (OR 2.36, CI 1.18–4.71), in smokers (OR 1.88, CI 1.02–3.46), and perioperative bleeding (OR 1.05 for intervals of 100 ml blood loss, CI 1.02–1.07).
Conclusion  Anastomotic leakage after anterior resection for low rectal tumours is related to the level, male gender, smoking and perioperative bleeding. Faecal diversion is advisable after total mesorectal excision of low rectal tumours in order to prevent AL.     

Endoscopic transanal resection of rectal adenomas using the urological resectoscope

Objective  Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital.
Method  Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed.
Results  Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10–65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2–162 months), local recurrences occurred in 13% ( n  = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections.
Conclusion  ETAR is simple and safe for managing rectal adenomas.     

Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.     

全直肠系膜切除直肠癌根治术：附126例报告

目的 评价全直肠系膜切除在直肠癌根治术中的应用价值.方法 对近126例中下段直肠癌患者行全直肠系膜切除术的临床资料进行回顾性分析.结果 2例(1.6%)高龄患者死于术后肺部感染.术后发生吻合口瘘2例(1.6%),术后随访1～5年,2年局部复发率为4.0%,3年生存率为93.6%,5年生存率为85.4%.结论 只要合理选择手术适应证.直肠癌全直肠系膜切除术可降低局部复发率,不增加并发症.     

Mesorectal lymph node dissection: is it beneficial?

Locoregional recurrences and distant metastases are the determinants of the long-term prognosis following curative resection of rectal carcinoma. While distant metastases cannot be affected by the surgical treatment of the primary tumor, avoidance of local recurrence by the surgeon is of special significance as the predominant prognostic factor. Analysis of the long-term results achieved by various surgeons led to the concept of mesorectal excision – the removal of the rectum together with all additional tissue invested by the adjacent visceral fascia, that is, fatty tissue, lymph nodes, and lymphatic vessels, by sharp dissection of the appropriate anatomical plane. In our own patient material the 5-year survival rate following R0 resection was 85% for all stages, provided no local recurrence developed. This contrasts with a figure of only 23% in those who did develop local recurrence. The local recurrence rate decreased from 39.4%, with a 50% 5-year survival rate in 1974, to 9.8% and a 71% survival rate in 1991, although the rate of distant metastases remained constant. Among the patients treated between 1988 and 1994 the local recurrence rate was determined by depth of infiltration (1987 UICC classification: pT1 0%, pT2 10%, pT3 14%, pT4 28%), extent of lymph node infiltration (pN0 6%, pN1 15%, pN2 26%, pN3 25%), grading (G1 9%, G2 12%, G3 21%), and location within the rectum (upper third 13%, middle third 8%, lower third 17%), with combinations of unfavorable initial factors leading to higher local recurrence rates. The elevated local recurrence rates seen in the 1970s, in particular in the case of tumors of the lower third, were traced retrospectively to incomplete mesorectal excision, the implementation of which reduced the local recurrence rate initially to less than 10%, and then to the current 4.1%. From the oncological point of view, mesorectal excision must be considered to confer considerable benefit. In the case of carcinomas of the upper third of the rectum, mesorectal resection carried out to just 5 cm below the lower tumor edge is sufficient, however, without coning, while deeper carcinomas mandate total mesorectal excision. Received: 21 October 1998 / Accepted: 26 October 1998     

Carcinoma of the rectum: a 10-year experience

A consecutive series of 303 patients with carcinoma of the rectum and distal sigmoid colon treated by a single surgeon over a 10-year period are reported. Of these, 202 underwent an anterior resection, 85 an abdominoperineal excision of the rectum and 16 a coloanal anastomosis. Surgery was considered palliative in 52 patients undergoing anterior resection and 24 undergoing abdominoperineal resection. The 30-day hospital mortality rate was six patients (3 per cent) for anterior resection and two patients (2 per cent) for abdominoperineal resection. Peroperative anastomotic testing demonstrated leakage in five stapled anastomoses; these were rectified and no clinical sequelae occurred. Two patients (1 per cent) developed a clinical anastomotic leak, one of which proved fatal; in each case the intraoperative test was negative. The overall 5-year survival rate was 64 per cent after anterior resection and 52 per cent after abdominoperineal resection; the median follow-up was 64 months. The incidence of local pelvic recurrence was 6.4 per cent after anterior resection and 14 per cent after abdominoperineal (not significant). These results confirm the success of sphincter-saving anterior resection combined with total mesorectal excision, routine full mobilization of the splenic flexure and cancercidal lavage of the distal rectum in the treatment of low rectal carcinomas; morbidity, local recurrence and survival are not compromised.     

全直肠系膜切除术在中低位直肠癌治疗的应用

目的:探讨全直肠系膜切除术在中、低位直肠癌治疗的应用。方法:回顾总结69例行全直肠系膜切除术的中、低位直肠癌病例,分析其疗效、局部复发、并发并发症的处理及预防。结果:围手术期死亡率1.45％(1/69);5年生存率67.6％(25/37);2年局部复发率5.8％(4/69);发生吻合口瘘和吻合口狭窄分别为6例(8.7％)和5例(7.25％)。结论:全直肠系膜切除术可有效降低局部复发率和提高生存率,因而是治疗中、低位直肠癌的理想手术。     

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients

OBJECTIVE: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. SUMMARY BACKGROUND DATA: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. METHODS: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. RESULTS: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. CONCLUSIONS: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.     

The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma

Background Although experience of laparoscopic treatment of rectal carcinoma has been reported, there is no evidence of its oncological safety because most procedures included partial mesorectal excision or abdominoperineal excision and quality of surgery is lacking. The aim of this study was to assess the oncological results of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma.Methods From 2000 to 2003, 144 patients underwent laparoscopic total mesorectal excision with low colorectal or coloanal anastomosis for mid and low rectal adenocarcinoma. There were 88 men and 56 women, with a median age of 65 years. The tumor was located at 5.5 cm (range 1–12) from the anal verge and was classified uT1T2 in 25 cases and uT3 in 119 cases. One hundred twenty patients received preoperative radiotherapy.Results Postoperative mortality and morbidity were 1% and 34% respectively. Conversion was 14% (n = 20). Macroscopic assessment of the specimen (n = 92) showed an intact mesorectum in 88% of the cases. The distal margin and the circumferential margin were safe in 98% and 94% of the cases, respectively. A complete microscopic excision, i.e., R0 resection, was achieved in 134 cases (93%). Pathological data were similar to those of an open match group. With a median follow-up of 18 months, there was no port-site recurrence and two patients had local recurrence (1.4%). The 3-year overall and disease- free survival rates were 89% and 77%, respectively.Conclusions A high quality of surgical excision can be achieved by the laparoscopic dissection, suggesting that this approach in treatment of rectal carcinoma is oncologically safe.     

The impact of pre- or postoperative radiochemotherapy on complication following anterior resection with en bloc excision of female genitalia for T4 rectal cancer

Objective  The aim of the study was to assess the mortality and morbidity following extended anterior resection with excision of internal female genitalia combined with pre- or postoperative chemoradiotherapy in women with extensive rectal cancer.
Method  The study included a consecutive series of 21 women with T4 adenocarcinoma of the rectum infiltrating the reproductive organs treated with curative intent between 1997 and 2003. All patients had an extended anterior sphincter preserving resection of the rectum (total mesorectal excision) and hysterectomy with or without posterior vaginal wall excision. In all patients, surgery was combined with adjuvant radiochemotherapy. Ten patients received preoperative radiotherapy (50.4 Gy) concurrently with two courses of chemotherapy [fluorouracil with folinic acid (FA)] followed by surgery within 6–8 weeks and subsequently four courses of postoperative chemotherapy. Eleven received postoperative chemoradiotherapy (50.4 Gy plus fluorouracil with FA).
Results  There was no postoperative mortality. Postoperative complications were observed in 57% patients (early in 14% and late in 52%). These included: anterior resection syndrome with anorectal dysfunction in 52% (requiring proximal diversion in 5%), urinary complications in 24% (complete incontinence requiring a permanent catheter in 5%). In addition, postoperative acute bleeding requiring relaparotomy, delayed wound healing caused by superficial infection, anastomotic leakage, prolonged bowel paralysis, benign rectovaginal fistula and anastomotic stricture occurred (5% each). The risk of postoperative morbidity (52%) was similar for patients with or without preoperative radiochemotherapy.
Conclusion  Despite this aggressive therapeutic approach, most postoperative complications were transient or could be treated. Preoperative radiochemotherapy did not increase the risk of morbidity.     

Local Recurrence following Total Mesorectal Excision with Double-stapling Anastomosis for Rectal Cancers: Analysis of Risk Factors

This study reviewed the local recurrence rate in patients who had undergone total mesorectal excision and double-stapling low anterior resection for mid and distal rectal cancers. It also aimed to identify risk factors for local recurrence through univariate and multivariate analyses. Consecutive patients with rectal cancers within 12 cm of the anal verge treated with total mesorectal excision and double-stapling low anterior resection from August 1993 to December 2000 were studied. The demographic data, operative details, tumor characteristics, and follow-up data were collected prospectively. Factors that might affect the local recurrence rate were analyzed with univariate and multivariate analyses. A total of 270 patients were included in the study (156 men, 114 women). The mean +/- SD age was 64.83 +/- 11.27 years. The mean +/- SD level of the tumor was 7.17 +/- 1.90 cm. All anastomoses were performed within 5 cm of the anal verge. During the mean follow-up of 35.5 months, 12 patients developed local recurrence. The 5-year actuarial local recurrence rate was 7.3%. The presence of lymphovascular invasion and the resection margin of < or = 1 cm were found to be risk factors for local recurrence in the univariate analysis. In the multivariate analysis, the presence of lymphovascular invasion was the only independent factor for local recurrence. In the group of patients with lymphovascular invasion, proximal tumors (6-12 cm from the anal verge) were shown to have a significantly lower local recurrence than those within 6.1 cm from the anal verge (4.2% vs. 37.8%; p <0.001). Low anterior resection performed with double stapling and total mesorectal excision achieved a local recurrence rate of 7.3%. The presence of lymphovascular invasion was the only independent risk factor for local recurrence. A high local recurrence rate was associated with distal cancers (? 6 cm from the anal verge) with lymphovascular invasion. Adjuvant therapy for local control should be considered for this subgroup of patients.     

Laparoscopic surgery of rectal carcinoma. Radical oncology and late results

The rectal cancer is one of the big challenges for laparoscopic surgery. From August 1993 to October 1999, at our hospital 108 rectal cancers including all UICC stages were laparoscopically operated on, 83 cases of them with curative intention. 77% of the carcinomas were situated in the middle or lower rectal third. A rectal amputation was performed in 13% of the cases, a continuity resection in 87%. All valid histopathological quality criteria were fulfilled: en bloc resection, total mesorectal excision, distal tumor free resection edge, and truncal dissection of the lower mesenteric artery. 25 lymph nodes per specimen were histopathologically described on average. All preparations of curative operations were assessed as R0 resections. In a median follow up of 30 months we saw locoregional recurrences in 1.2% and a recurrence-free survival in 90%. In a subpopulation with 4 years follow up, the rate of local recurrences was 2%, and the recurrence-free survival 85.7%. The value of multimodal therapy concepts in total mesorectal excision cannot be assessed at present yet. Laparoscopic rectal surgery is a very effective treatment option for rectal cancer, but it should be practiced only in specialized centres.     

Surgical treatment of extraperitoneal rectal cancer

The aim of the study was to evaluate the results of open surgery with sphincter preservation and nerve-sparing total mesorectal excision and a fast-track protocol, without a protective stoma in a consecutive series of patients with extraperitoneal rectal cancer. From 1998 to 2007, 89 patients with extraperitoneal rectal cancer were treated according to a prospective protocol. Eight-six patients were submitted to anterior resection with a low or ultra-low anastomosis and nerve-sparing total mesorectal excision. Fifty-four patients received neoadjuvant therapy. Twenty-eight patients were treated according to a fast-track postoperative protocol. Primary protective colostomies were performed in 6 cases (6.9%), while a secondary colostomy was necessary in 3 patients (3.4%). There was just one postoperative death (1.1%) and major morbidity occurred in 12.3%. Seven patients developed anastomotic dehiscence; 3 were successfully treated with a secondary colostomy and 4 were treated conservatively. 68.4% of the patients treated with the fast-track protocol could be discharged on postoperative day 4. 73% of patients were still surviving at a 5-year follow-up (48 patients). The incidence of local recurrences was 3.1%. Anterior resection in the form of open nerve-sparing total mesorectal excision with selective use of neoadjuvant therapy can be successfully performed without a protective stoma in more than 80% of patients. The fast-track protocol seems to increase the quality of the patient's postoperative condition and reduce the hospital stay.     

Clinical significance of macroscopic completeness of mesorectal resection in rectal cancer

Aim Local recurrence after resection of rectal cancer is usually regarded as being due to a ‘failure’ of surgery. The completeness of resection of the mesorectum has been proposed as an indicator of the ‘quality’ of the resection. We determined the prognostic value of macroscopic evaluation of rectal cancer resection specimens and the circumferential resection margin (CRM) after curative surgery. Method From 1999 to 2006, the macroscopic quality of the mesorectum and the CRM were prospectively assessed in 127 patients who underwent rectal cancer resection with curative intent (R0+R1). Chemoradiotherapy was administered for 61 tumours staged as locally advanced tumours (T3, T4 and N+). Univariate analysis of time to local recurrence and cancer‐free survival were tested (Kaplan–Meier) and multivariate analysis calculated with a Cox regression model. Results The mesorectum was incomplete in 34 (26.8%) patients. At a median follow up of 34 months (range, 9–96 months), in the group with an adequate mesorectal excision, the cumulative risk of local recurrence at 5 years was 10%. This was 25% if the mesorectum was incomplete (P < 0.01). Five‐year cancer‐free survival was 65% if the mesorectal excision was adequate and 47% if it was not (P < 0.05). Multivariate analysis identified T status, the CRM and the mesorectal score as independent factors for local recurrence, and T and N status and the mesorectal score as independent factors for disease‐free survival. Conclusion The outcome of surgical treatment of rectal cancer is related to the completeness of mesorectal excision. It is a more discriminative prognostic factor than the classic tumour–node–metastasis (TNM) system.     

Rectal cancer with macroscopic peritoneal involvement – clinical challenges and consequences

Objective  In gastrointestinal cancer, serosal involvement indicates advanced disease. We looked at the possible role of clinical peritoneal involvement (CPI) in local recurrences (LRs) and the overall survival of patients with rectal cancer (RC).
Method  Between 1993 and 2002, 6404 patients were diagnosed with RC. Based on macroscopic findings at surgery and corresponding histological findings, 166 patients (3%) had CPI. Surgery was stratified according to type and extent of operation: as resective or nonresective surgery and as curative (R0) or noncurative (R1 or R2) resection.
Results  The presence of CPI was a negative factor for survival with a median of 15 months (95% CI, 12–19) in the presence of CPI compared with 65 months (95% CI, 61–70) without it ( P  < 0.001). In R0 resections, the median survival was 97 months (95% CI, 90–102) in patients without CPI compared with 48 months (95% CI, 22–74) in patients with CPI ( P  < 0.001). In R1 or R2 resections, the median survival was 16 months (95% CI, 15–17) in the absence of CPI and 9 months (95% CI, 8–10) in the presence of CPI. The LR rate in patients without CPI was 10.2% compared with 15.7% in patients with CPI ( P  = 0.022).
Conclusions  Clinical peritoneal involvement is a significant detrimental prognostic factor for the LR of RC and survival in the absence of metastases. Observations from this large national cohort add to what is known about peritoneal involvement. Diagnosed CPI should be taken into consideration when adjuvant treatment strategies are addressed.     

Quality of mesorectum after laparoscopic resection for rectal cancer - Results of an audited teaching programme in Spain

Objective  The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer.
Method  In April 2006, the Spanish Association of Surgeons started an audited teaching programme. The project was similar to the Norwegian one and several training courses were arranged. Patients were classified into two groups: laparoscopic rectal resection (LR) and open rectal resection (OR). The quality of the mesorectum was scored: complete, nearly complete or incomplete. The circumferential margin (CRM) was considered positive, if tumour was located 1 mm or less from the surface of the specimen.
Results  Between 2006 and 2008, 604 patients underwent rectal resection with total mesorectal excision for rectal cancer: 209 patients were included in the LR group and 395 patients in the OR group. There were no differences in terms of number of lymph nodes affected, distance of the tumour from CRM. The mesorectum was complete in 464 (76.8%), nearly complete in 91 (15.1%) and incomplete in 49 patients (8.1%). CRM was negative in 534 patients (88.4%). No differences were observed between the two groups. The overall postoperative morbidity rate was 38.8% in LR group and 44.6% in OR group ( P  = 0.170). Overall postoperative mortality rate was 2.5%. One patient died (0.5%) in the LR group and 14 patients died (3.5%) in the OR group ( P  = 0.021).
Conclusion  Laparoscopic resection for rectal cancer is feasible with the quality of mesorectal excision and postoperative outcomes similar to those of open surgery.     

V6The feasibility of laparoscopic rectal resection for cancer

Introduction:  Total mesorectal excision (TME) has offered the lowest recurrence rates and best survival in rectal cancer patients. Recently several multi-centre trials have demonstrated the feasibility of laparoscopic colonic resections for cancer. However the technical difficulties and lack of supporting data has prevented surgeons from attempting laparoscopic TME for operable rectal cancer. We present a video demonstration of lap TME technique performed at our unit for rectal cancer resections.
Methods:  The surgical technique involves using two 10 mm and two 5 mm ports to perform rectal resections. Adherence to advanced oncological principles like high tie of IMA and IMV is the rule. Splenic flexure is routinely mobilised for mid to low rectal cancers. Total mesorectal excision is performed using diathermy hook. Rectal washout is performed before transection of the rectum using lap stapler device.
Results:  Between October 2006–December 2007, 30 rectal cancers have been operated laparoscopically at our institution using this technique. There were four APER and 26 anterior resections. The median age was 72 years with a median BMI of 25. Median operative time was 235 min with a median hospital stay of 7 days. There were no leaks.
Conclusions:  With proper training and experience, laparoscopic rectal cancer resection is technically feasible and safe to perform with good oncological outcomes.