Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors

AIM:To assess the efficacy of full-thickness excision using transanal endoscopic microsurgery(TEM) in the treatment of rectal neuroendocrine tumors.METHODS:We analyzed the data of all rectal neuroendocrine tumor patients who underwent local full-thickness excision using TEM between December 2006 and December 2014 at our department. Data collected included patient demographics,tumor characteristics,operative details,postoperative outcomes,pathologic findings,and follow-ups. RESULTS:Full-thickness excision using TEM was performed as a primary excision(n = 38) or as complete surgery after incomplete resection by endoscopic polypectomy(n = 21). The mean size of a primary tumor was 0.96 ± 0.21 cm,and the mean distance of the tumor from the anal verge was 8.4 ± 1.4 cm. The mean duration of the operation was 57.6 ± 13.7 min,and the mean blood loss was 13.5 ± 6.6 m L. No minor morbidities,transient fecal incontinence,or wound dehiscence was found. Histopathologically,all tumors showed typical histology without lymphatic or vessel infiltration,and both deep and lateral surgical margins were completely free of tumors. Among 21 cases of complete surgery after endoscopic polypectomy,9 were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. Norecurrence was noted during the median of 3 years' follow-up.CONCLUSION:Full-thickness excision using TEM could be a first surgical option for complete removal of upper small rectal neuroendocrine tumors.     

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994–2003

Background and aims This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution.Patients and methods One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures.Results The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5–100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006).Conclusion With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.     

Rectal cancer

PURPOSE: This study was designed to assess the local recurrence rate and prognostic factors for local recurrence in patients undergoing curative anterior or abdominoperineal resections without radiotherapy. METHODS: From January 1980 to December 1996, 514 consecutive patients underwent curative resections for rectal cancer. We excluded those with preoperative radiotherapy (n=23), postoperative radiotherapy (n=27), local resection (n=36), and 11 (2.1 percent) patients who died postoperatively. The remaining 417 patients (249 males) with a median age of 64 (range, 21–90) years were analyzed. For upper third lesions, mesorectal tissue was excised down to at least 5 cm below the tumor. Total mesorectal excision was performed for lower and middle tumors. Postoperative chemotherapy was limited to patients with Stage III lesions. Median follow-up (and 95 percent confidence interval) was (5.2 4.3–5.9) years, with 87.7 percent of patients followed up longer than 24 months. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis. RESULTS: Five-year local recurrence rate(and 95 percent confidence interval) was 9.7 (6.4–13) percent, with a median time to diagnosis of 15 (10–23) months. Local recurrence rates in Stages I, II, and III were: 3.1, 4.1, and 24.1 percent, respectively (P < 0.0001). In relation to node status, local recurrence rates were N0, 4.1 (1.7–6.5) percent; N1, 12.6 (4.6–20.6) percent; N2, 32.1 (12.1–52.1) percent; and N3, 59.3 (22.5–96.1) percent; (P < 0.00001). Lower third tumors had a higher local recurrence rate than middle and upper third tumors: 17.9, 7.1, and 5.1 percent, respectively (P=0.002). Adjusted by stage, this difference was maintained only in Stage III tumors. Among lower tumors, those at 6 and 7 cm from the anal verge had a lower local recurrence rate than those below 6 cm (6.7vs. 26.2 percent, respectively;P=0.02). Accidental rectal perforation at or near the tumor site occurred in 12 cases (2.9 percent), showing a strong correlation with local recurrence (P < 0.0001). Multivariate analysis showed significant higher risk for lower third tumors (hazard ratio, 2.98) and positive nodes (hazard ratio, 4.78). CONCLUSIONS: Appropriate surgery without irradiation achieves excellent local control in N0 rectal cancers. Node metastasis, lower third localization (especially below 6 cm), and accidental rectal perforation at or near the tumor site are significantly associated with a higher local recurrence rate.     

The Effect of Circumferential Tumor Location in Clinical Outcomes of Rectal Cancer Patients Treated With Total Mesorectal Excision

PURPOSE A positive circumferential resection margin is associated with a high risk of local recurrence and distant metastasis after total mesorectal excision for rectal cancer. The mesorectum is thinner anteriorly than posteriorly, and the risk of a positive resection margin may be higher for anterior than for posterior tumors. We sought to determine the effect of the tumor's position in the circumference of the rectum on the treatment and outcomes of rectal cancer patients treated by total mesorectal excision. METHODS We retrospectively analyzed 401 patients with rectal cancer staged by preoperative endorectal ultrasound and treated by sharp mesorectal excision with or without neoadjuvant therapy. Tumors were classified into four groups (anterior, posterior, lateral, and circumferential) according to the location of deepest point of penetration on endorectal ultrasound. Differences in recurrence and survival rates were analyzed with logistic regression analysis. RESULTS Of the 401 tumors, 27 percent were anterior, 26 percent posterior, 32 percent lateral, and 15 percent circumferential. The groups did not differ in age, gender, tumor distance from the anal verge, or tumor grade. The ultrasound and pathology stages were more advanced in the circumferential group, and the proportion of uT4 tumors was higher in the anterior group. Circumferential and anterior tumors were more likely to receive preoperative adjuvant radiation. After an average follow-up of 44 months, 20 percent of patients had developed recurrence (13 percent distant, 6 percent local, and 1 percent distant and local). Recurrence was associated with advanced tumor stage, tumor proximity to the anal verge, and no preoperative adjuvant therapy. Early tumor stage and preoperative chemoradiation were associated with lower recurrence and improved survival. When tumor stage was controlled for, patients with poor or undifferentiated tumors and male patients with anterior tumors were shown to have a higher risk of recurrence or death. The estimated five-year disease-free survival for the entire group was 73 percent. CONCLUSIONS Tumor stage is the main criterion to estimate prognosis in rectal cancer patients. The position of the tumor within the circumference of the rectum may provide valuable clinical information. Anterior tumors tend to be more advanced and, at least in male patients, has a higher risk of recurrence and death than tumors in other locations. Presented at the meeting of the Minnesota Surgical Society, St. Paul, Minnesota, April 27, 2001.     

Colorectal anastomosis using a novel double-stapling technique for lower rectal carcinoma

Background The conventional double-stapling technique (DST) using a standard linear stapler horizontally is sometimes difficult to apply to an anastomosis where the pelvis is narrow or the anastomosis is ultralow. In this report, we review our experiences of a novel DST (IO-DST) that employs vertical division of the rectum using an endostapler. Materials and methods One-hundred and five consecutive patients who underwent low anterior resection for rectal carcinoma below the peritoneal reflection were enrolled into this study. The clinical, oncological, and functional outcomes were studied retrospectively. Results The median distance from the anal verge to the tumor was 5.0 cm in “high risk” T1 tumors and 6.5 cm in more-advanced tumors. More than 2 cm of distal surgical margin was obtained in 80.6% of the patients with tumors deeper than T1. The median distance from the anal verge to the anastomosis was 4.2 cm in T1 tumors and 4.0 cm in more-advanced tumors. The median blood loss was 315 ml, and the median operative time was 262 min. There was no mortality in the IO-DST. Recurrence presented in 12 (13.0%) of the patients who underwent curative surgery, with local recurrence in four patients (4.3%) during a median follow-up of 46.2 months. However, no patients experienced suture-line recurrence. The early bowel frequency was four times/day after stoma closure in patients with transient covering colostomy and 3.5 times/day in patients without colostomy. The late bowel frequency was three times/day in patients with transient covering colostomy, and two times/day in patients without colostomy. Conclusions The IO-DST is a feasible and safe procedure for facilitating lower anastomosis in rectal carcinoma below the peritoneal reflection.     

超声内镜引导深挖活检联合黏膜切除术诊治早期直肠类癌

目的 探讨超声内镜引导下深挖活检早期诊断直肠类癌以及内镜下黏膜切除术治疗直肠类癌的安全性、有效性。方法在超声内镜引导下深挖活检、结合病理及免疫组化检查,诊断直肠类癌24例。对24例直肠类癌的内镜及超声影像特点进行回顾性分析,总结其特征。对病灶直径小于1．5cm、浸润深度不超过黏膜下层、无肝转移及腹水发生的直肠类癌采取内镜下黏膜切除术治疗。结果24例直肠类癌分别距离肛缘5cm～12cm,病灶大小0．8cm～1．5cm,术后切除的标本切缘完整,基底无残留,治疗过程中均未发生穿孔,无迟发性出血,术后创面即刻渗血1例,经内镜治疗血止。随访3至5年无转移及再发。结论直肠类癌可通过超声内镜引导下深挖活检,钳取组织行病理及免疫组化检查而确诊,内镜下黏膜切除术治疗直径小于1．5cm的直肠类癌简单、安全有效。     

Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum

INTRODUCTION: Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum. METHODS: This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor margin 1.3±0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical procedure of a mechanical anastomosis by means of a circular stapler. After intersphincteric rectal resection, the anastomosis was handsewn, using interrupted sutures from the perineal approach, 2.5 to 3 cm above the anal verge, implementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively. RESULTS: Complications: Postoperative mortality was 0 percent. Postoperatively, none of the patients showed an indication for relaparotomy. The leakage rate was 48 percent. Only 16 percent later needed additional surgery for anastomotic strictures or for rectovaginal fistulas. Long-term observations showed that the anastomosis healed well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient). Follow-up: During the follow-up period of 6.8±3.7 years, six patients (19.4 percent) developed a tumor progression (9.7 percent local recurrences and 12.9 percent distant spread). The five-year survival rate was 79 percent (Dukes A, 100 percent (n=18); Dukes B, 67 percent (n=4); and Dukes C, 44 percent (n=9)). Continence: One-third of patients developed anorectal incontinence for liquid (29.6 percent) or solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105±37 cm H₂O and postoperative, 75±19 cm H₂O;P<0.05), whereas squeeze pressure did not change. CONCLUSION: In selected patients with tumors close to the dentate line, an intersphincteric resection of the rectum may help to avoid an abdominoperineal excision of the rectum with a terminal stoma, without any curtailemtn of oncologic standards. A protective stoma for three months is advantageous.     

Rectal carcinoids: The most frequent carcinoid tumor

One hundred seventy patients with gastrointestinal carcinoid tumors were treated at Ochsner Clinic from 1958 to 1990. Ninety-four rectal carcinoid tumors were diagnosed and treated during this time. Carcinoid tumors of the rectum represented the most frequent primary site (55 percent), followed by carcinoids of the ileum (12 percent), appendix (12 percent), colon (6 percent), stomach (6 percent), jejunum (2 percent), pancreas (2 percent), and other (5 percent). One-half of rectal carcinoids were discovered during anorectal examination of asymptomatic patients. The remainder were found primarily by examination of patients for symptoms of benign anorectal conditions. The diagnosis of rectal carcinoid was made at the time of initial examination in 61 patients. This allowed definitive treatment in a single session by local excision and fulguration in 48 patients. The remainder were treated by repeat biopsy and fulguration (25 patients) or by transanal excision (12 patients). Overall, 85 carcinoid tumors of the rectum measuring <2 cm were treated by local excision and fulguration or by transanal excision, with an average five-year follow-up. There were no local recurrences. Ten patients with metastasizing rectal carcinoids averaging 4 cm were treated. All were symptomatic at presentation and fared poorly despite radical surgery. Three were alive at three years but only one survived five years. At our institution, rectal carcinoids were the most frequently detected carcinoid tumor. Small carcinoids of the rectum were adequately treated by local excision and fulguration or by transanal excision, with no local recurrence. The true incidence of rectal carcinoids is detected only with careful and complete rectal examination of the asymptomatic screening population by experienced surgeons. With more widespread screening of the well population, rectal carcinoids may become recognized as the most frequent human carcinoid tumor.Read at the XIIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Graz, Austria, June 24 to 28, 1990.     

Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

PURPOSE Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.METHODS All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.RESULTS Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39–43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2–90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.CONCLUSIONS Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 7, 2002.     

Preoperative Chemoradiotherapy and Total Mesorectal Excision Surgery for Locally Advanced Rectal Cancer: Correlation With Rectal Cancer Regression Grade

PURPOSE Preoperative long-course chemoradiotherapy is recommended for rectal carcinoma when there is concern that surgery alone may not be curative. Downstaging of the tumor can be measured as rectal cancer regression grade (1-3) and may be of importance when estimating the prognosis. The aim of this study was to look at the long-term results of tumor regression in patients receiving long-course chemotherapy before surgical resection of rectal cancer.METHODS We reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinoma of the mid rectum or distal rectum found to be stage T3/4 between January 1995 and November 1999. Patients received 45 to 50 Gy irradiation in 2-Gy fractions and an infusion of 5-fluorouracil. Surgical specimens were assessed for rectal cancer regression grade. Patients were followed up routinely with clinical examination, computed tomography, and colonoscopy.RESULTS Sixty-five patients with a mean age 65 (range, 32–83) years underwent chemoradiotherapy before surgical resection. Thirty patients (46 percent) were classified as rectal cancer regression Grade 1, with 9 patients (14 percent) having complete sterilization of the tumor. Fifty-three patients (82 percent) underwent a curative resection. Overall survival, with a median follow-up of 39 (range, 24–83) months, was 67 percent and was associated with tumor downstaging. The local recurrence rate was 5.8 percent in those patients who underwent a curative resection and was significantly lower with rectal cancer regression Grade 1 tumors (P = 0.03). Eight of nine patients (89 percent) whose tumor had been sterilized were alive and well with no recurrence of tumor at a median follow-up of 41 (range, 24–70) months.CONCLUSIONS Preoperative chemoradiotherapy resulted in significant regression of tumor. Overall survival was high and was associated with downstaging of tumor. The local recurrence rate was significantly lower with rectal cancer regression Grade 1 tumors and was not seen in patients with sterilized tumors.Presented at the Association of Coloproctology of Great Britain and Ireland, Manchester, United Kingdom, July 2002.Reprints are not available.     

经术前治疗转化低位直肠间质瘤一例

胃肠道间质瘤累及直肠少见,仅占直肠恶性肿瘤的0.1%,但危险等级高,总体预后不良。尤其低位直肠间质瘤,更为罕见,既往治疗以手术为主,总体保肛率不高,并容易损伤邻近周围组织器官。现报道1例女性低位直肠间质瘤患者,予以口服伊马替尼术前治疗转化后,行肛门肿物切除术,术后继续予以口服伊马替尼,随访7个月未见复发。对于部分初始不可切除或切除困难,以及手术可能对相邻脏器功能产生较严重影响的特殊部位间质瘤,经伊马替尼进行术前治疗后有望获得手术机会且减少对脏器功能的损伤。     

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent

PURPOSE: This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery. METHODS: During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumors of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence. RESULTS: Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank,P=0.01 andP=0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank,P=0.38). CONCLUSIONS: When a mesorectal excision is performed, circumferential margin involvement is more an indicator of advanced disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.Research was performed at the General Infirmary at Leeds, Leeds, United Kingdom.     

Treatment outcomes of endoscopic resection for rectal carcinoid tumors: an analysis of the resectability and long-term results from 46 consecutive cases

Aim: In Japan, most of colorectal carcinoid tumors developed in rectum. The choice of treatment is important because surgical treatment may need to construct artificial anus. Although curative endoscopic resection (ER) is desirable from the point of quality of life, sufficient evidence of endoscopic treatment for rectal carcinoid tumors is not fully obtained.

Methods: Between April 2001 and August 2013, 46 rectal carcinoid tumors in 46 patients who underwent either with endoscopic mucosal resection with a ligation device (EMR-L) or endoscopic submucosal dissection (ESD) were analyzed retrospectively. The rates of en bloc resection, positive for lateral and/or vertical margin, curative resection, local recurrence, additional treatments, overall and disease-specific survival rate after ER were evaluated during follow-up (median observation period 61.6 months).

Results: Twenty-two lesions were treated by EMR-L and 24 lesions were treated by ESD. Both groups had similar mean tumor size (EMR-L: 6.2?mm, ESD: 6.0?mm). The rate of en bloc resection, negative for both lateral and vertical margins, and curative resection were, respectively, 73%, 63%, and 50% for EMR-L, 100%, 100%, and 83% for ESD. These results suggested that the rate of resectability and curability for ESD was significantly higher than EMR-L (p?Conclusion: The long-term outcomes of ER for rectal carcinoid tumors were excellent. ESD has advantage for resectability and curability compared with EMR-L; therefore, ESD is more favorable procedure as treatment for rectal carcinoid tumors.     

Curative local excision in the treatment of carcinoma of the rectum

A safe, simple technique of curative local excision is used for early invasive carcinoma of the rectum. Strict criteria were applied in selecting patients for curative local excision: (1) the tumor was less than 3cm in diameter; (2) there were no clinically involved pelvic lymph nodes; (3) the tumor had a pedicle or pseudopedicle, and (4) subsequent histopathologic examination showed that the tumor was confined to the mucosa and submucosa of the bowel wall and completely excised. Curative local excision in 16 patients had no operative mortality or morbidity. The five-year cancer specific survival was 100 per cent, which compares favorably with the 88 per cent cancer specific survival rate in 268 patients managed by conventional curative resection for Dukes' stage A tumors. When the 7.1 per cent operative mortality of resection was additionally considered, the five-year survival fell to 81 per cent. The probability of lymph-node metastases in primary rectal tumors confined to the mucosa and submucosa was found to be 6.2 per cent irrespective of their diameter,i.e., slightly less than the mortality of resection. Supported by a grant from the Anti-Cancer Council of Victoria.     

直肠类癌32例临床及病理分析

目的探讨直肠类癌的临床病理特点及治疗。方法对32例经病理诊断的直肠类癌患者的临床资料进行回顾分析,总结其临床表现、治疗情况及随访结果。结果直肠类癌以腹痛(10/32)、大便习惯改变(15/32)、便血(5/32)为主要临床表现,部分为无症状体检时发现直肠黏膜下肿物(5/32)。29例直肠类癌位于肛门8cm以内,内镜下主要表现为半球状隆起,表面黏膜正常。其中17例行超声内镜检查,肿块多位于黏膜下层,为均匀或不均匀稍低回声,边界清晰。内镜下行EMR治疗32例,1例追加外科手术治疗。22例随访5月～5年,1例因伴肝、肺转移死亡,余21例无复发。结论直肠类癌缺乏特异性临床表现,诊断主要靠内镜及组织学检查,内镜下EMR切除是主要治疗方法。     

Laparoscopic resection of lower rectal cancer with telescopic anastomosis without abdominal incisions

AIM:To assess laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions.METHODS:From March 2010 to June 2014, 30 patients(14 men and 16 women, aged 36-78 years, mean age 59.8 years) underwent laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through anus-preserving transanal resection.The tumors were 5-7 cm away from the anal margin in 24 cases, and 4 cm in six cases.In preoperative assessment, there were 21 cases of T1N0M0 and nine of T2N0M0.Through the middle approach, the sigmoid mesentery was freed at the root with an ultrasonic scalpel and the roots of the inferior mesenteric artery and vein were dissected, clamped and cut.Following the total mesorectal excision principle, the rectum was separated until the anorectal ring reached 3-5 cm from the distal end of the tumor.For perineal surgery, a ring incision was made 2 cm above the dentate line, and sharp dissection was performed submucosally towards the superior direction, until the plane of the levator ani muscle, to transect the rectum.The rectum and distal sigmoid colon were removed together from the anus, followed by a telescopic anastomosis between the full thickness of the proximal colon and the mucosa and submucosal tissue of the rectum.RESULTS:For the present cohort of 30 cases,the mean operative time was 178 min,with an average of 13 positive lymph nodes detected.One case of postoperative anastomotic leak was observed,requiring temporary colostomy,which was closed and recovered3 mo later.The postoperative pathology showed T1-T2N0M0 in 19 cases and T2N1M0 in 11 cases.Twelve months after surgery,94.4%patients achieved anal function Kirwan grade 1,indicating that their analfunction returned to normal.The patients were followed up for 1-36 mo,with an average of 23 mo.There was no local recurrence,and 17 patients survived for3years(with a survival rate of 100%).CONCLUSION:Laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions is safe and feasible.     

Characteristics and long-term prognosis of patients with rectal neuroendocrine tumors

AIM:To analyze the clinicopathologic characteristics and prognostic factors of rectal neuroendocrine tumors.METHODS:The records of 48 patients with rectal neuroendocrine tumors who were treated at the Cancer Institute and Hospital,Chinese Academy of Medical Sciences,Beijing,from March 2004 to September 2009were retrospectively reviewed.The clinicopathological data were extracted and analyzed,and patients were followed-up by telephone or follow-up letter to determine their survival status.Follow-up data were available for all 48 patients.Uni-and multivariate Cox regression analyses were performed to determine the prognostic factors significantly associated with overall survival.RESULTS:The tumors occurred mostly in the middle and lower rectum,and the most prominent symptoms experienced by patients were hematochezia and diarrhea.The median distance between the tumors andthe anal edges was 5.0±2.257 cm,and the median diameter of the tumors was 0.8±1.413 cm.The major pathological type was a typical carcinoid tumor,which accounted for 93.8%(45/48)of patients.Tumor-nodemetastasis(TNM)stagesⅠ,Ⅱ,ⅢandⅣtumors accounted for 78.8%,3.9%,9.6%and 7.7%of patients,respectively.The main treatment method,in 72.9%(35/48)of patients,was transanal extended excision.The 1-,3-and 5-year survival rates of the whole group of patients were 100%,93.7%,and 91.3%,respectively.Univariate analysis showed that age(P=0.032),tumor diameter(P<0.001),histological type(P<0.001),TNM stage(P<0.001),and surgical approach(P=0.002)were all prognostic factors.On multivariate analysis,only the pathological type was shown to be an independent prognostic factor(HR=2.797,95%CI:1.676-4.668,P=0.004).CONCLUSION:In patients with rectal neuroendocrine tumors,TNM stage Ⅰ is the most common stage found,and lymph node or distant metastases are rarely seen.The pathological type of the tumor is an independent prognostic factor.     

Outcome of radical excision of anorectal gastrointestinal stromal tumors in Hong Kong Chinese patients.

Anorectal gastrointestinal stromal tumor (GIST) is a rare disease entity with malignant potential. Medical records of six patients (median age 68 years) with anorectal GIST who underwent surgical treatment at our institution between 1992 and 1999 were retrospectively reviewed. Four patients presented with rectal bleeding. The tumors were located in the mid and lower rectum in 4 patients and in the anal canal in 2 patients. The median tumor diameter was 4.5 cm. One patient who had undergone local excisions in another hospital presented with recurrent GIST. He refused radical excision and underwent wide local excision again. He developed recurrence 2 years later and underwent salvage pelvic exenteration, but finally died of disseminated disease. Five patients underwent initial radical excision. Among them, 3 developed recurrences (one each local, distant and both) at a median duration of 50.3 months. Two patients died of the disease, while one patient who had both local and distant recurrences resected remained alive till the end of the study period (median duration of follow-up of the 5 patients was 84.6 months). At 5 years, of 5 patients who underwent initial radical excision, 3 and 4 patients, respectively, had disease-free and overall survival. Recurrence of anorectal GIST is common despite radical excision. Nevertheless, a reasonable survival rate can be achieved.     

Long-term follow-up of local excision and radiation therapy for invasive rectal cancer

PURPOSE: Little is known regarding the long-term outcome of patients with rectal cancer treated by local excision and radiation therapy. We updated our institutional experience with this approach. METHODS: From January 1986 to December 1991, 23 patients (median age, 64 (range, 30–80) years) with mobile, moderately differentiated adenocarcinoma of the rectum were offered transanal excision. Two patients with large T3 tumors, who were judged intraoperatively to be unsuited for a local procedure, received radical resection and were excluded from analysis. Twenty-one patients underwent transanal excision en bloc (14) or piecemeal (7) through a resectoscope. Seventeen patients (74 percent) had either extensive medical problems or refused a colostomy. Patients received a median of 5,040 cGy postoperatively, and 15 also received 500 cGy preoperatively on protocol. Two patients received concomitant chemotherapy. Median follow-up is 56 months for all patients and 67 months for survivors (range, 27–92 months). RESULTS: There were 2 T1, 15 T2, and 4 T3 tumors. The distance from the anal verge was a median of 4 (range, 1–7) cm. The median tumor size was 3 (range, 2–7) cm. Sixteen patients had more than one-third of the wall involved. Four patients (19 percent) developed a local recurrence at 26, 30, 33, and 48 (median, 31.5) months. Three were salvaged (abdominoperineal resection = 2; low anterior resection = 1) and remain disease-free 18, 36, and 37 months postoperatively. Four patients (19 percent) developed metastases (lung = 3; liver = 1) at 3, 22, 25, and 44 months after initial treatment (median, 23.5 months). The actuarial five-year overall, disease-free and recurrence-free survival are 77, 75, and 58 percent, respectively. Twelve patients (57 percent) have no evidence of disease while retaining their rectum. There was one postoperative death. CONCLUSIONS: Long-term follow-up confirms that local excision and radiation therapy is of value in patients with mobile tumors of the rectum. It suggests that this treatment can be offered to those patients who refuse a colostomy or are medically compromised and may be an acceptable option for selected patients with T2 or T3, mobile adenocarcinomas of the rectum.     

早期直肠癌的局部切除治疗

直肠癌是最常见的恶性肿瘤之一,目前外科手术方式包括经腹根治术及局部切除术等方式。随着近年早期直肠癌诊断率逐渐提高,局部切除术也逐渐增加。研究表明,对于严格筛选的早期直肠癌病人,局部切除术较经腹根治手术术后排便及性功能障碍发生率低,同时能获得与根治性手术相似的治疗效果。但由于局部切除术未清扫区域淋巴结,存在较高的局部复发率,需要术前对肿瘤局部浸润及淋巴结状态的精确评估,同时进行良好的术后随访和监测。