全直肠系膜切除和术前放化疗对直肠癌局部复发的影响

目的 研究全直肠系膜切除和术前治疗对直肠癌局部复发的影响。方法 2000年1月至2004年8月间接受全直肠系膜切除手术的161例直肠癌患者作为研究组；1996年1月至1999年12月间接受直肠癌手术的173例患者作为对照组。收集两组患者的临床病理和随访资料，比较其手术并发症、局部复发情况的差异。结果两组患者手术并发症发生率比较（P〉0．05），差异无统计学意义。研究组肿瘤局部复发率为2．5％，低于对照组的8．0％（X^2=5．144；P=0．023）。研究组中57例接受术前治疗，肿瘤局部复发率为1．8％；而没有接受术前治疗患者的肿瘤局部复发率为3．0％（X^2=1．781，P=0．182）；差异无统计学意义。将患者性别、年龄、手术方式、全直肠系膜切除与否、接受术前治疗与否、肿瘤大体类型、分化程度、分期、脉管癌栓、辅助化疗等因素作为协变量，以肿瘤局部复发作为因变量行Logistic回归分析。结果 显示全直肠系膜切除和脉管癌栓是影响直肠癌局部复发的主要因素。结论 全直肠系膜切除和脉管癌栓有无是影响直肠癌局部复发的主要因素。     

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.     

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.     

Laparoscopic sphincter‐preserving total mesorectal excision: 10‐year report

Aim Total mesorectal excision (TME) is currently the gold standard for resection of mid or low rectal cancer and is associated with a low local recurrence rate. However, few studies have reported the long‐term oncological outcome following use of a laparoscopic approach. The aim of this study was to evaluate the long‐term oncological outcome after laparoscopic sphincter‐preserving TME with a median follow up of about 4 years. Method Patients with mid or low rectal cancer who underwent laparoscopic sphincter‐preserving TME with curative intent between March 1999 and March 2009 were prospectively recruited for analysis. Results During the 10‐year study period, 177 patients underwent laparoscopic sphincter‐preserving TME with curative intent for rectal cancer. Conversion was required in two (1%) patients. There was no operative mortality. At a median follow‐up period of 49 months, local recurrence had occurred in nine (5.1%) patients. The overall metastatic recurrence rate after curative resection was 22%. The overall 5‐year survival and 5‐year disease‐free survival in the present study were 74% and 71%, respectively. Conclusion The results of this study show that laparoscopic sphincter‐preserving TME is safe with long‐term oncological outcomes comparable to those of open surgery.     

Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial

OBJECTIVE: This study was performed to identify tumor- and patient-related risk factors for distal rectal cancer in patients treated with an abdominoperineal resection (APR) associated with positive circumferential resection margin (CRM), local recurrence (LR), and overall survival (OS). BACKGROUND: The introduction of total mesorectal excision (TME) has improved the outcome of patients with rectal cancer. However, survival of patients treated with an APR improved less than of those treated with low anterior resections (LAR). Besides, an APR is associated with a higher LR rate. METHODS: Patients were selected from the TME trial, which is a randomized, multicenter trial, studying the effects of preoperative radiotherapy (RT) in 1861 patients. Of the Dutch patients, 455 underwent an APR. Location of the bulk of the tumor was scored with surgery, pathology, or other reports. CRM was available from pathology reports. RESULT: A positive CRM was found in 29.6% of all patients, 44% for anterior, 21% for lateral, 23% for posterior, and 17% for (semi)circular tumor location (P < 0.0001). In a multivariate analysis, T-stage, N-stage, and tumor location were independent risk factors for CRM. If a (partial) resection of the vaginal wall was performed in women, 47.8% of patients still had a positive CRM. T-stage, N-stage, and CRM were risk factors for LR and age, T-stage, N-stage, CRM, and distance of the inferior tumor margin to the anal verge for OS. CONCLUSION: Age, T-stage, N-stage, CRM, distance of the tumor to the anal verge, and tumor location were independent risk factors for adverse outcome in patients treated with an APR for low rectal cancer. Anterior location, specifically in women, more often requires downstaging and/or more extended resection to obtain free margins.     

Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy

BACKGROUND: Variability in rates of local recurrence following resection of rectal cancer has led to the suggestion that all patients should undergo preoperative radiotherapy. This centre employs a selective policy of radiotherapy only in patients with evidence of advanced local disease determined by preoperative staging. METHODS: A retrospective review was carried out of 114 consecutive patients with rectal cancer. Patients were divided before operation into palliative and curative groups based on preoperative staging. Only patients in the palliative group were offered preoperative radiotherapy. Total mesorectal excision (TME) was performed for all tumours of the middle or lower rectum. RESULTS: The perioperative mortality rate was 0.9 per cent and anastomotic dehiscence occurred in 2.8 per cent. Local recurrence developed in 4 per cent of patients in the 'curative' group and in seven of 15 of those assigned to the palliative group before operation (P < 0.01). Positive lateral resection margins were significantly associated with a risk of subsequent recurrence (ten of 13 versus three (3 per cent) of 93; P < 0.001). CONCLUSION: Preoperative adjuvant radiotherapy can be omitted reasonably in patients in whom there is no evidence of locally advanced disease, provided that adequate surgery, incorporating TME for low tumours, is performed.     

直肠癌根治术后局部复发危险因素分析

目的 探讨影响直肠癌根治术后局部复发的相关因素,为直肠癌治疗提供依据.方法 回顾性分析1994年8月至2004年6月间收治的535例直肠癌根治手术病例的临床资料和随访结果,比较各临床病理因素与局部复发的关系.结果 本组局部复发53例(9.9%),其中合并远处复发转移病例39例(7.3%).首次手术至复发时间4～54个月,中位时间12个月.单因素分析显示,肿瘤位置(P<0.001)、分化程度(P<0.001)、组织学分型(P=0.038)、有无淋巴结转移(P=0.023)、Dukes分期(P=0.045)、有无输血(P=0.001)和术中是否应用全直肠系膜切除术(TME)原则(P<0.001)与肿瘤根治术后局部复发有关;而手术方式(P=0.908)、肿瘤浸润深度(P=0.735)、肿瘤大体病理分型(P=0.562)、手术医生年资(P=0.171)和术后辅助化疗与否(P=0.772)与根治术后局部复发无关.多因素分析显示,输血情况、肿瘤位置、分化程度、淋巴结转移和术中TME的应用是直肠癌根治术后局部复发的影响因素.结论 有输血、肿瘤位置低、分化程度低和有淋巴结转移的直肠癌患者较易复发,术中严格遵守TME原则是降低直肠癌术后局部复发的关键.     

新辅助放化疗联合全直肠系膜切除术治疗中低位进展期直肠癌的临床研究

目的：探讨新辅助放化疗联合全直肠系膜切除（TME）手术治疗中低位进展期直肠癌的疗效及安全性。方法回顾性分析2010年1月至2011年1月收治的56例中低位进展期直肠癌患者临床资料,28例接受新辅助放化疗联合TME手术治疗,设为观察组;28例仅接受TME手术,设为对照组。观察两组患者治疗前后TNM分期、肿瘤标志物水平及不良反应,比较两组切缘无癌细胞（R0）切除率、保肛率、局部复发率及转移率。结果观察组新辅助放化疗后TNM分期显著改善,与治疗前相比较差异有统计学意义（μ=1.960,P=0.000）;癌胚抗原CEA及糖链抗原CA19-9、CA242、CA724等肿瘤标志物水平均显著降低,与治疗前相比较差异有统计学意义（t值分别为9.276、8.716、9.420、6.512,均P＜0.01）。观察组R0切除率（89.28%vs 60.71%,χ2=6.095,P=0.014）及保肛率（75.00%vs 32.14%,χ2=10.338,P=0.001）均显著高于对照组。随访1年,观察组术后局部复发率（7.14%vs 28.57%,χ2=4.383,P=0.036）及远处转移率（21.43%vs 46.43%,χ2=3.903,P=0.048）显著低于对照组,差异有统计学意义。结论新辅助放化疗联合TME手术治疗中低位局部进展期直肠癌疗效确切,值得临床推广使用。     

Anterior Resection for Rectal Cancer with Mesorectal Excision: Institutional Review

This study aims to compare the operative results and oncological outcomes of patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer. Anterior resection has become the preferred treatment option for 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. Resection of primary rectal and rectosigmoid cancer was performed in 298 patients from January 2003 to November 2010. These 298 patients (163 men and 135 women; median age, 67 years) underwent anterior resection. The curative resection was performed in 269 patients (90.3 %). TME was performed in 202 patients (67.8 %). 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 malegender, the absence of stoma, and increased blood loss. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. 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.     

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??Management of complete response after neoadjuvant chemoradiotherapy in rectal cancer SU Xiang-qian, YANG Hong. Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education)??Department of Minimally Invasive Gastrointestinal Surgery??Peking University Cancer Hospital & Institute??Beijing 100142??China
Corresponding author: SU Xiang-qian??E-mail: suxiangqian@bjmu.edu.cn
Abstract Neoadjuvant chemoradiotherapy (CRT) followed by radical surgery including total mesorectal excision (TME) is standard treatment in patients with locally advanced rectal cancer. The benefits of neoadjuvant CRT have been well documented and include tumor regression and downstaging associated with increased tumor respectability, reduced local recurrence and a higher rate of sphincter preservation. Radical surgery for rectal cancer carries a high risk of morbidity and mortality and can also greatly detract from a patient’s quality of life. In light of the significant response rates that can be achieved with preoperative CRT, some scholars have suggested limiting further surgical therapy to local excision alone or to observation for patients with clinical complete response (cCR). This article summarizes the latest development of management strategies for complete responders after neoadjuvant CRT for rectal cancer.     

低位Ⅰ期直肠癌患者的外科治疗与预后分析

目的探讨低位Ⅰ期直肠癌的外科治疗效果及影响复发和预后的因素。方法回顾性分析166例低位Ⅰ期直肠癌患者的临床资料。结果本组根治性手术138例，均按直肠全系膜切除（TME）手术原则进行；其中93例行腹会阴联合根治术，45例行保肛手术；肿瘤局部切除术28例。局部复发率根治性手术者为5．1％（7／138），其中腹会阴联合根治术组为6．5％（6／93），保肛术组为2．2％（1／45）；局部切除术组为17．9％（5／28）。X^2检验显示，肿瘤分化程度（P=0．009）和手术方式（P=0．039）与局部复发相关。腹会阴联合根治术组5年生存率为90．4％，保肛术组为95．5％。局部切除术组为82．6％。单因素分析显示，肿瘤分化程度（P=0．000）和局部复发（P=0．000）与预后相关；多因素分析显示，局部复发是影响预后的主要因素（P=0．000）。结论低位Ⅰ期直肠癌根治性手术切除复发率低、预后好。局部切除术的选择应严格把握指征。     

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??Management of clinical complete response after neoadjuvant chemoradiotherapy in low rectal cancer LUO Shuang-ling??KANG Liang. Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen Universiry,Guangzhou 510655,China
Corresponding author: KANG Liang,E-mail: eonkang@163.com
Abstract Neoadjuvant chemoradiotherapy ??CRT?? followed radical surgery including total mesorectal excision ??TME?? is standard treatment in patients with locally advanced rectal cancer. The benefits of neoadjuvant CRT have been well documented and include tumor regression and downstaging associated with increased tumor respectability??reduced local recurrence and a higher rate of sphincter preservation. Radical surgery for rectal cancer carries a high risk of morbidity and mortality and can also greatly detract from a patient’s quality of life. In light of the significant response rates that can be achieved with preoperative CRT??some scholars have suggested limiting further surgical therapy to local excision or just wait and see. Recently?? several studies have explored the feasibility and efficacy of organ-preserving strategies for low rectal cancer. Therefore?? it’s a new challenge for clinician to choose how to treat the situation with clinical complete response after neoadjuvant therapy for low rectal cancer patients.     

Transanal Endoscopic Microsurgery (TEM) Resection of Rectal Tumors

Local excision of rectal cancer is an attractive alternative to avoid the morbidity associated with radical rectal surgery. Oncologic concerns, specifically the inability to fully assess the status of the perirectal lymph nodes and the risk of local recurrence after local excision remain significant barriers to widespread adoption of this technique. Transanal endoscopic microsurgery is an alternative minimally invasive technique used for transanal excision of rectal polyps and tumors. It offers the advantage of better exposure, magnified stereoscopic view, and greater reach into the middle and upper rectum. This technique, combined with careful patient selection, has demonstrated optimistic results compared to standard transanal techniques and even total mesorectal excision when utilized for certain early rectal cancers. This study was presented at the Society for Surgery of the Alimentary Tract meeting, May 23, 2006, Los Angeles, CA, USA     

Treatment of rectal cancer: reduction of local recurrence after the introduction of TME - experience from one University Hospital

BACKGROUND: Local recurrence (LR) of cancer after rectal surgery is followed by significant morbidity and mortality. Since the introduction of total mesorectal excision (TME) the rates of LR have decreased in many centres. The aim of this retrospective study was to investigate the effect of TME on the recurrence rates of rectal cancer and the impact of the surgeons. METHODS: All patients resected for invasive rectal cancer from 1990 until 2000 were initially included in the study. From February 1994, TME was adopted as the standard treatment (TME group). Before this period, rectal surgery was performed by the non-TME technique (non-TME group). To obtain homogeneity, patients who underwent preoperative irradiation, emergency operations, pre- or intraoperative bowel perforation, residual tumour stage (R1,2) including Dukes' D stage and postoperative mortality within 31 days, were excluded. 139 patients in the non-TME group and 181 patients in the TME group were found eligible for analyses. RESULTS: The estimated LR rate at 1, 3 and 5 years was 7, 15 and 17% (non-TME) versus 4, 9 and 9% (TME) (p = 0.046, log-rank test). The anastomotic leakage rate was 6% (non-TME) versus 4% (TME) (not significant). Perioperative blood loss >500 ml, reoperations during the hospital stay and lymph node (N) stage were the independent risk factors for LR in the multivariate analysis. The case volume did not significantly influence LR rates. However, the variability of individual surgical results was reduced after the introduction of TME. CONCLUSIONS: TME yields significantly lower LR rates compared with traditional surgery. Since the introduction of TME, experience with rectal surgery has been gathered by a limited number of surgeons. The results of individual surgeons have consistently improved and the variability of individual surgical results is now at a lower level.     

经肛门切除内括约肌治疗超低位直肠癌的保肛手术47例临床经验

目的报告在直肠癌全系膜切除术（totalmesorectal excision TME）基础上采用内括约肌切除（intersphincter resection ISR）治疗超低位直肠癌的手术经验和初步结果。方法患者选自2000年3月至2008年12月的超低位直肠肿瘤患者47例。,男29例,女18例,年龄34～75岁。手术方式：腹部手术施行TME,会阴部手术施行ISR。术后随访,了解患者术后肛门功能、有无肿瘤的局部复发和转移。结果本组患者均施行该手术,手术无死亡。术后随访3个月-8年,平均3年10个月,46例手术后获得较好的肛门功能,Kirwan分级1～4级。2例手术后直肠癌局部复发,其中1例死亡。2例手术后肛门狭窄,再次手术扩肛。结论内括约肌切除（ISR）治疗超低位直肠癌的保肛手术,是一种安全可行的手术方式,可以达到在根治性的前提下保留肛门的目的。     

提高直肠肿瘤局部复发患者的生存率及生命质量

Despite progress in the understanding of perirectal anatomy and subsequent adoption of total mesorectal excision,local recurrence after curative resection for rectal cancer continues to be a significant concern.Local recurrence of rectal cancer is associated with a wide spectrum of clinical symptoms and morbidities,and decreased quality of life.The management of locally recurrent rectal cancer is challenging because of the altered pelvic anatomy,postoperative adhesion and difficulty in obtaining a definite diagnosis before surgery.Surgery is the mainstay treatment for locally recurrent rectal cancer,and the use of radiation and chemotherapeutic agents provides significant improvement in survival rate and quality of life.     

Abdominoperineal Resection via Total Mesorectal Excision and Autonomic Nerve Preservation for Low Rectal Cancer

p = 0.0003). Poorer survival was statistically related to the presence of positive lymph nodes ( p = 0.0009). Overall, local recurrence rates were 5% (8/148) in patients without distant metastases, and 15% to 21% in patients with positive nodes. Positive lymph nodes, N ₂ disease, lymphatic vascular invasion, and perineural invasion were independent significant risk factors for local recurrence. Sexual function was preserved in approximately 57% of patients undergoing APR versus 85% of patients undergoing sphincter preservation. No significant urinary morbidity was encountered. Low rectal cancer requiring APR seems to be a disease with more locally advanced disease and adverse pathologic features than are seen with mid-rectal cancers treatable by low anterior resection. APR when performed in accordance with the principles of TME and ANP ensures the greatest likelihood of resecting all regional disease while preserving both sexual and urinary functions. Preoperative combined modality treatment may be warranted in all T ₃ or greater low rectal cancers.     

Sphincter preservation — A fascinating challenge in rectal carcinoma surgery

Background: In the last decades there has been an increasing trend toward sphincter preservation for rectal cancer. This paper analyses a uniformly operated patient collective with regard to complication, tumor recurrence and survival rates. Methods: Between January 1984 and July 1993, 440 patients were operated for rectal cancer. In the upper rectal third sphincter preservation was possible in 100%, in the middle third in 97% and in the lower third in 46%. Results: Tumor resection was possible in 98.9%, curative resection in 85.7% of the 440 surgically treated patients. Anastomotic leakage was observed in 10.5%, postoperative hospital mortality for curatively operated patients was 1.9%. The 5-year actuarial survival rates for tumor stages I to IV were 99%, 77%, 44% and 20% respectively. The local recurrence rate was 12.7%. Conclusions: A high rate of sphincter preservation can be achieved without sacrificing low morbidity, mortality or recurrence rates. The surgical trend towards sphincter preservation in the middle and lower rectal thirds is due to the increased application of stapler devices and to the histopathological examination of the distal and lateral resections margins. The mesorectum is recognized as an important source of local tumor recurrence.     

Resection of rectal cancer: A historical review

Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques and adjuvant therapy. By applying advanced surgical principles, surgeons can now excise most rectal cancers completely, often preserving the anal sphincter and leaving the patient with relatively normal bowel and pelvic function. Historically, the earliest surgical approaches to rectal cancer were via the perineum. As surgical techniques and general anesthesia improved, other approaches such as a posterior approach were undertaken to improve access to the whole rectum. Consequently, abdominoperineal resection became the standard treatment until anterior resection was introduced for proximal rectal cancers. The most important surgical breakthrough in recent years has been the advent of total mesorectal excision (TME). The emphasis in rectal cancer surgery is on preservation of function, with dissection being done in appropriate anatomical planes. Thus, mobilization of the rectum has a long history, and is seen in modern procedures including TME and intersphincter resection. This article reviews the progression of the surgical management of rectal cancer with reference to historical perspectives. We discuss the major surgical considerations for mobilization of the rectum in several surgical procedures, from conventional operations to modern standardized TME.