Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study

Background The role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer. Methods A prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted. Results The study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001). Conclusions As compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.     

Laparoscopic surgery for the curative treatment of rectal cancer: results of a Chinese three-center case–control study

Background  This study aimed to assess the efficacy and safety of laparoscopic resection (LR) for rectal cancer. Methods  A case-control study involving three Chinese medical centers was conducted. Rectal cancer patients undergoing LR were compared with open resection (OR) cases simultaneously from January 2004 to December 2005. Data were collected, and basic characteristics, conversion rate, recovery, complications, adjuvant therapy, and recurrence rate were compared. Analysis was by intention to treat. Results  A total of 335 rectal cancer procedures (115 LR and 220 OR) met the inclusion criteria. The patients’ basic characteristics were similar in the two groups (p > 0.05). Total mesorectal excision was performed for 85.59% of the patients (201/235), who received anal sphincter preservation. Compared with OR, LR had a shorter incision length, less blood loss, and less need for transfusion, but the operation time was longer (p < 0.05). No significant differences were observed between the two groups in positive rates of longitudinal resection margins, numbers of harvested lymph nodes, complication rates during operation and postoperation, and perioperative reoperation and morbidity rates (p > 0.05). Postoperative parenteral narcotics were used less in LR than in OR (47.8% vs 62.7%; χ² = 6.867; p = 0.009). The median time until first flatus; resumption of diet, defecation, micturition, and ambulation; and discharge were reduced in LR (p < 0.05). Conversion from LR to OR was required by 11.3% of the patients (13/115). The intraoperative complication rate was 30.8% for the patients who underwent conversion. The operation time and postoperative complication rate were the same as for LR alone (p > 0.05). The local recurrence rate was 3.7% for the LR group and 4.9% for the OR group (χ ² = 0.209; p = 0.647) during the 20-month median follow-up period. Conclusions  The findings showed that LR for rectal cancer was safe and effective, resulting in faster recovery and a similar complication rate compared with OR. Conversion did not alter the patients’ outcomes.     

Open vs laparoscopic repair of full‐thickness rectal prolapse: a re‐meta‐analysis

Objective A re‐meta‐analysis of available data within the published literature comparing laparoscopic rectopexy (LR) with open repair (OR). Method We searched MEDLINE, EMBASE, CINAHL, PubMed and the Cochrane databases from January 1990 to October 2008. We searched the following MESH terms: ‘laparoscopy’, ‘prolapse’ and ‘rectal prolapse’. We used the following text words: ‘rectopexy’, ‘haemorrhoids’, ‘minimally invasive’ and ‘keyhole surgery’. The bibliography of selected trials and a Cochrane review was scrutinized and relevant references obtained. Selected trials were analysed to conduct a meta‐analysis. Results Twelve comparative studies on 688 patients qualified for the review. There were 330 patients in LR group and 358 in the OR group. LR takes longer to perform compared with OR. This difference was statistically significant [random effects model: standardized mean difference (SMD) 1.63, 95% CI (1.14–2.12), z = 6.56, P < 0.001]. There was a significant reduction in hospital stay between LR vs OR [random effects model: SMD ?1.75, 95% CI (?2.45 to ?1.05), z = ?4.90, P < 0.001]. There was no statistical difference relating to morbidity, constipation, incontinence or mortality between the two groups. Conclusion laparoscopic rectopexy is a safe and effective modality and is comparable to OR, however, there is still a paucity of randomized controlled trials within the literature regarding this subject. Until these trials are conducted, we would advise caution in deriving absolute conclusions.     

Laparoscopy as a prognostic factor in curative resection for node positive colorectal cancer: Results for a single-institution nonrandomized prospective trial

Background Several studies reporting preliminary long-term survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy.Methods A single-institution prospective nonrandomized trial compared short- and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000.Results In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid–low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR (p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) (p = 0.09). The mean number of lymph nodes retrieved were 13.8 ± 5.7 for OR and 12.7 ± 5; for LR (p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid–low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancer-related survival was identifyed in stage III patients undergoing LR.Conclusions Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and long-term survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.     

Recurrence and Quality of Life Following Perineal Proctectomy for Rectal Prolapse

Background  Surgical outcome and quality of life (QOL) following perineal proctectomy for rectal prolapse remain poorly documented. Methods  From 1994 to 2004, patients with full-thickness rectal prolapse were treated exclusively with perineal proctectomy independent of age or comorbidities. Subjective patient assessments and recurrences were determined retrospectively from hospital and clinic records. Consenting patients completed the gastrointestinal quality of life index (GIQLI). Results  Perineal proctectomy was performed in 103 consecutive patients with a median age of 75 years (range 30–94). Most patients underwent concurrent levatorplasty (anterior 85.8%, posterior 67.9%). Durable results were obtained in all patients; the recurrence rate was 8.5% over a mean follow-up of 36 months. Preoperatively, 75.5% of patients reported fecal incontinence, and 32.1% had obstructed defecation. Incontinence significantly improved post-proctectomy (41.5%, p < 0.001), as did constipation (10.4%, p < 0.001). GIQLI respondents reported satisfaction following proctectomy with 63% scoring within one standard deviation of healthy controls. Patients with recurrent prolapse reported a lower QOL. Risk factors for recurrence included duration of prolapse, need for posterior levatorplasty, and prior anorectal surgery. Conclusions  Perineal proctectomy provides significant relief from fecal incontinence and obstructive symptoms caused by rectal prolapse, with an acceptable recurrence rate and low morbidity. This study was supported exclusively using institutional funding.     

It’s the procedure not the patient: the operative approach is independently associated with an increased risk of complications after rectal prolapse repair

Aim This study compares 30‐day outcomes following rectal prolapse repair, examining potential surgical and patient factors associated with perioperative complications. Method Using the NSQIP database, patients with rectal prolapse were categorized by surgical approach to repair (perineal or abdominal) and abdominal cases were further subdivided by procedure (resection compared with rectopexy alone). Univariate and multivariate analyses compared major and minor complication rates between the groups. Results Of 1275 patients, the perineal group (n = 706, 55%) was older, with more comorbidity, than those undergoing an abdominal procedure. There were fewer minor (odd ratio (OR) = 0.35; 95% confidence interval (CI), 0.20–0.60; P = 0.0038) and major complications (OR = 0.46; 95% CI, 0.31–0.80; P = 0.0038) in the perineal compared with the abdominal cohort. There was a significant increase in major complications amongst patients undergoing a resection compared with rectopexy only (OR = 2.15; 95% CI, 1.10–4.41; P = 0.0299). There was no difference in major complications between abdominal rectopexy and a perineal approach, but the latter had a lower chance of minor complications (OR = 0.47; 95% CI, 0.24–0.94; P = 0.0287). Conclusion A perineal approach is safer than an abdominal approach to the treatment of rectal prolapse. Regarding an abdominal operation, rectopexy has fewer major complications than resection.     

Full‐thickness neorectal prolapse after transanal transabdominal proctosigmoidectomy for low rectal cancer: a cohort study

Aim

Transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis is an alternative to abdominoperineal excision of the rectum (APR) for low rectal cancer. Neorectal prolapse is an unusual complication following TATA. This study aimed to determine the incidence of neorectal prolapse after TATA for low rectal cancer.

Method

This cohort study was conducted in a tertiary referral colorectal centre. From a prospectively maintained database including 1093 patients treated for rectal cancer between 1984 and 2016 we identified those who underwent sphincter‐preserving surgery. Data regarding the incidence, management and outcomes of neorectal prolapse were analysed.

Results

A total of 409 patients were identified, of whom 185 underwent open surgery and 224 a minimally invasive surgical procedure (MIS). All received neoadjuvant chemoradiation. Neorectal prolapse occurred in 4.6% (n = 19) with an incidence of 2.2% in the open and 6.7% in the MIS group (P = 0.023), with no difference between MIS techniques. There was one recurrence of neorectal prolapse (5.9%). The incidence of neorectal prolapse was higher in women (9.5%) than men (2.5%) (P = 0.011). There were no differences in local recurrence rates between the neorectal prolapse group (5.3%) and our population without prolapse (3.4%) (P = 0.79).

Conclusion

Neorectal prolapse is a rare occurrence following minimally invasive sphincter‐saving surgical procedures performed for rectal cancer. It appears to be more frequent in patients who undergo MIS procedures and in women.     

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

Background: Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer. Methods: A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patients choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l–9 years). Results: We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group (p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group (p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group (p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery (n = 10) and patients who had undergone surgery in the past year (n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection (p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group (p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection (p = 0.162), whereas for Dukes stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 (p = 0.392), 0.722 vs 0.584 (p = 0.199), and 0.500 vs 0.417 (p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free (p = 0.623). Conclusions: Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international radomized controlled trials.     

Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer

Background: Transanal endoscopic microsurgery (TEM) has gained increasing acceptance as a local treatment of early rectal cancer. The purpose of this study was to compare the results of TEM and radical surgery in patients with T1 and T2 rectal cancer. Methods: From October 1994 to December 2000, 74 patients with T1 and T2 rectal adenocarcinoma treated with TEM were compared with 100 patients with T1N0M0 and T2N0M0 rectal adenocarcinoma treated with radical surgery. Retrospective analysis was performed regarding to recurrence and survival rate. Neither group received adjuvant chemoradiation. There was no significant difference in age, gender, tumor location, or follow-up period between the two groups. The only difference was in tumor size. Results: Of the 74 patients in TEM group, 52 were T1 (70.3%) and 22 were T2 (29.7%). Of the 100 patients in radical surgery group, 17 were T1 (17%) and 83 patients were T2 (83%). The 5-year local recurrence rates were 4.1% for T1, 19.5% for T2 after TEM, 0% for T1, and 9.4% for T2 after radical surgery. There was no statistical difference between the TEM and radical surgery groups for T1 rectal cancer (p = 0.95), but for T2 rectal cancer, the 5-year local recurrence rate was higher after TEM than after radical surgery (p = 0.04). There were no significant statistical difference between the two groups in terms of the 5-year disease-free survival rate and the survival rate. Conclusions: For T1 rectal cancer, there was no difference in recurrence or 5-year survival rate between the TEM and the radical surgery groups. For T2 rectal cancer, there was no statistical difference in the 5-year survival rate between the two groups, but TEM carried higher risk of local recurrence. Therefore, careful selection of the patients is required for TEM, and when proper muscle invasion is proven, the TEM procedure should be supplemented by further treatment, or radical surgery should be performed. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) meeting and the 8th World Congress of Endoscopic Surgery, New York, New York, USA, 13–16 March 2002     

Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients

Background We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki. Methods Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV. Results The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good. Conclusions Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.     

Combined surgery in pelvic organ prolapse is safe and effective

Objective In women, rectal prolapse is often accompanied by other signs of generalized pelvic floor weakness including uterine and bladder prolapse. The purpose of this study was to compare whether there are differences in outcomes of rectal prolapse surgery between women having combined pelvic organ prolapse (POP) surgery with a urologist or urogynecologist (CS) vs those having abdominal rectal prolapse surgery alone (RP). Method Charts were reviewed to collect perioperative data on those having surgery from 1995 to 2001. Phone surveys were conducted to obtain Cleveland Clinic Foundation (CCF) Incontinence score, Knowles‐Eccersley‐Scott‐Symptom (KESS) Constipation Score, Short Form 36 (SF‐36) quality of life score and recurrence rate. Appropriate statistical analysis was performed. Results Ninety‐four operations were performed (23 CS and 71 RP). Forty‐six (49%) could be contacted by phone. Mean follow‐up was similar in both groups (CS 4.1 vs RP 3.6 years; P = 0.796). There were no significant differences between both groups regarding age, American Society of Anesthesiology classification Score, complications, length of hospital stay, CCF Incontinence score, KESS Constipation Score, SF‐36 Score and recurrence rate of rectal prolapse. The operative time (CS 226 vs RP 122 min; P < 0.001) and blood loss (CS 377 vs RP 183 ml; P < 0.001) were significantly increased in the CS group. Conclusion Combined surgery for POP is safe and effective when considering outcomes of rectal prolapse surgery. Therefore surgeons should not hesitate to address all pelvic floor issues during the same operation by working in partnership with the anterior pelvic floor colleagues.     

Salvage living donor liver transplantation versus repeat liver resection for patients with recurrent hepatocellular carcinoma and Child-Pugh class A liver cirrhosis: A propensity score-matched comparison

Following curative liver resection (LR), resectable tumor recurrence in patients with preserved liver function leads to deciding between a repeat LR and a salvage liver transplantation (LT), if a donor’s liver is available. This retrospective study compared survival outcomes and recurrence pattern following salvage living donor LT (LDLT) and repeat LR in patients with recurrent hepatocellular carcinoma (HCC). We reviewed the medical records of patients who underwent repeat LR (n = 163) or LDLT (n = 84) for recurrent HCC following curative resections, between January 2005 and December 2017 at a single institution. A 1:1 propensity score matching led to 42 patients per group. Disease-specific and recurrence-free survival were significantly better in the salvage LDLT group than in the repeat LR group (p = .042; HR = 2.40; 95% CI, 0.69–6.00 and p < .001; HR = 4.23; 95% CI, 2.05–8.71, respectively). Despite significant differences in recurrence patterns between the two groups (p = .019), the patient death rates, after recurrence, were similar for both groups (p = .760). This study indicates that salvage LDLT is superior to repeat LR for treating patients with transplantable, intrahepatic HCC recurrence, even in patients with Child-Pugh class A liver cirrhosis.     

314例直肠癌患者术后复发转移形式及其预后

目的 探讨直肠癌术后复发转移的形式、预后及其治疗对策.方法 回顾性研究1979年5月至2006年11月哈尔滨医科大学附属肿瘤医院行直肠癌手术治疗并术后复发转移的314例患者的临床资料.结果 全组患者局部复发168例（53.5%）,复发间隔期为（24.7±1.9）个月;远隔转移146例（46.5%）,远隔转移间隔期为（22.7±1.9）个月;远隔转移时间早于局部复发时间（P〈0.01）.复发时间段较早（P〈0.01）、腹膜反折以下（P=0.043）及术后未行放化疗（P=0.007）的患者发生局部复发的构成比高.局部复发组3年和5年生存率为0.48和0.25,生存期为（24.7±1.9）个月;远隔转移组3年和5年生存率为0.33和0.16,生存期为（22.7±1.9）个月,两组差异有统计学意义（P〈0.01）;Cox回归分析提示,复发早、TNM分期及治疗方式（包括手术方式和术后是否放化疗）是影响患者复发后生存的独立因素（均P〈0.01）.结论 直肠癌术后局部复发者预后优于远隔转移者：根治性切除可使术后复发患者生存显著获益.     

Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes

Our aim was to study the anatomic recurrence rates and quality of life outcomes of patients who had undergone either anterior colporrhaphy (AC) or anterior colporrhaphy and vaginal paravaginal repair (AC + VPVR) as part of surgery for pelvic organ prolapse. Chart reviews were used to identify anatomic prolapse recurrence. Phone interviews assessed quality of life outcomes [Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ)] outcomes. There was a trend towards longer time to anatomic recurrence (any compartment ≥grade 2) in the AC group compared with the AC + VPVR group (median 24 vs 13 months, p=0.069). If only patients who had undergone previous surgery were compared, time to anatomic recurrence appeared significantly longer in the AC group (median 41 vs 12 months, p=0.022). There were 55% of women in the AC group and 46% of women in the AC + VPVR group who reported significant bladder or bulge symptoms based on responses to the phone-administered UDI and IIQ (p=0.89). Our retrospective study did not suggest that adding VPVR was superior in terms of anatomic or quality of life outcomes. Prospective assessment of the role of VPVR in the treatment of pelvic organ prolapse is needed.     

Tumour budding correlates with local recurrence of rectal cancer

Aim Predictive tools for local recurrence (LR) of rectal cancer are needed. This study assessed the predictive value of tumour budding detected by MNF‐116 and laminin‐5 γ2 chain (Ln‐5 γ2). Method In a case–control study, the surgical specimens of 48 patients with LR after from primary resection of rectal carcinoma and 82 control patients matched for gender and preoperative radiation from a population of 1180 patients operated with total mesorectal excison were studied. The presence of budding was examined using immunohistochemistry with Ln‐5 γ2 and pan‐cytokeratin staining with MNF‐116. Results Tumour budding counts ranged from 0 to 106 buds (mean 43, median 38) for all patients. Significantly more tumours with more than 35 buds were seen in the LR than in the control group (67 vs 44%; P = 0.02). The spread of budding was also more extensive in the LR than in the control group (63 vs 49%, P = 0.03). In a multivariate analysis with tumour, node, metastasis stage, MNF‐116‐stained budding was an independent predictor of local failure (P = 0.02). The budding frequency was higher in irradiated tumours in comparison with tumours that had not received irradiation (mean 53 vs 38, P = 0.03). For Ln‐5 γ2, more tumours with ≥10 buds were seen in the group with LR than among the control patients, but this difference was not statistically significant (73 vs 57%; P = 0.09). No additive value was found in the multivariate logistic regression model when Ln‐5 γ2‐stained budding frequency was added to MNF‐116 and tumour, node, metastasis stage. The agreement between budding frequency determined by MNF‐116 and Ln‐5 γ2 was moderate, with a κ‐coefficient of 0.34 (0.16–0.51). Conclusion Tumour budding determined by MNF‐116 staining may serve as a predictive marker for LR in rectal cancer.     

Complete Pathologic Response after Combined Modality Treatment for Rectal Cancer and Long-Term Survival: A Meta-Analysis

Background

Complete pathologic response (CPR) after neoadjuvant chemoradiotherapy (combined modality treatment, CMT) for rectal cancer seems associated with improved survival compared to partial or no response (NPR). However, previous reports have been limited by small sample size and single-institution design.

Methods

A systematic literature review was conducted to detect studies comparing long-term results of patients with CPR and NPR after CMT for rectal cancer. Variables were pooled only if evaluated by 3 or more studies. Study end points included rates of CPR, local recurrence (LR), distant recurrence (DR), 5-year overall survival (OS), and disease-free survival (DFS).

Results

Twelve studies (1,913 patients) with rectal cancer treated with CMT were included. CPR was observed in 300 patients (15.6%). CPR and NPR patient groups were similar with respect to age, sex, tumor size, distance of tumor from the anus, and stage of disease before treatment. Median follow-up ranged from 23 to 46?months. CPR patients had lower rates of LR [0.7% vs. 2.6%; odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22?C0.90, P?=?0.03], DR (5.3% vs. 24.1%; OR 0.15, 95% CI 0.07?C0.31, P?=?0.0001), and simultaneous LR?+?DR (0.7% vs. 4.8%; OR 0.32, 95% CI 0.13?C0.79, P?=?0.01). OS was 92.9% for CPR versus 73.4% for NPR (OR 3.6, 95% CI 1.84?C7.22, P?=?0.002), and DFS was 86.9% versus 63.9% (OR 3.53, 95% CI 1.62?C7.72, P?=?0.002).

Conclusions

CPR after CMT for rectal cancer is associated with improved local and distal control as well as better OS and DFS.     

Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence,distant metastasis and reduced cancer‐specific survival?

Aim The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer‐specific survival was analysed. Method Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5‐year follow‐up were analysed with multivariate methods. Results After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour–node–metastasis stages I–III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5‐year cancer‐specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5‐year overall or 5‐year cancer‐specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy (P = 0.055) and rectal washout (P = 0.046) reduced the LR rate, but did not influence survival. Conclusion Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow‐up on the basis of the occurrence of AL after AR might not be justified.     

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis

Aim The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. Method The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. Results Five nonrandomized studies including a total of 5012 patients were identified. Meta‐analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43–0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39–0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42–0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39–0.98). Conclusion Taking into account the limitations of the design of the included studies the meta‐analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.     

Risk factors of rectal cancer local recurrence: population‐based survey and validation of the Swedish rectal cancer registry

Aim Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high‐risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Method Local recurrence and survival rates of 4153 patients registered 1995–1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. Results The 5‐year overall and cancer‐specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0‐resections for tumours in TNM stages I–III, LR developed in 10% of tumours at 0–5 cm, 8% at 6–10 cm and 6% at 11–15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0–5 cm: OR 0.50 (0.30–0.83), 6–10 cm: OR 0.42 (0.25–0.71), and 11–15 cm: OR 0.29 (0.13–0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48–4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43–1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Conclusion Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow‐up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.     

Short- and midterm outcomes of laparoscopic surgery compared for 131 patients with rectal and rectosigmoid cancer

Background This study aimed to clarify and compare the short- and midterm surgical outcomes of laparoscopic surgery for rectal and rectosigmoid cancer. Methods Between June 1992 and December 2004, 131 selected patients with cancer of the rectum (n = 60) and rectosigmoid (n = 71) underwent laparoscopic surgery. The indications for laparoscopy included a preoperative diagnosis of T1/T2 tumor in the rectum and T1–T3 tumors in the rectosigmoid. Results The mean follow-up period was 42 months. The procedures included anterior resection for 117 patients, abdominoperineal resection for 11 patients, Hartmann’s procedure for 1 patient, and restorative proctocolectomy for 1 patient. Conversion to an open procedure occurred for four patients (3.1%). Postoperative complications developed in 29 patients (22.1%), including anastomotic leakage in 14 patients (11.8%). The length of hospital stay for the rectal cases was significantly longer than for the rectosigmoid cases (10 vs 7 days; p = 0.0049). The tumor node metastasis (TNM) stages included 0 (n = 14), I (n = 72), II (n = 15), III (n = 29), and IV (n = 1). Recurrences were experienced by 13 patients, including local recurrence (n = 7) and recurrences involving the liver ((n = 2), lung (n = 3), and distant lymph nodes (n = 1). The 5-year disease-free and overall survival rates were, respectively 91.7% and 97.9% for stage I, 86.7% and 90.9% for stage II, and 77.1% and 90.0% for stage III. Conclusions Laparoscopic surgery is feasible and safe for selected patients with rectal or rectosigmoid cancer. The selected patients in this study experienced favorable short- and midterm outcomes.