Circumferential resection margin involvement after laparoscopic abdominoperineal excision for rectal cancer

Aim This study aimed to evaluate circumferential resection margin (CRM) involvement in patients with rectal adenocarcinoma after laparoscopic abdominoperineal excision (APR). Method Prospectively collected data were analyzed on consecutive patients who underwent laparoscopic APR for histologically proven rectal cancer following neoadjuvant chemotherapy, from 1998 to 2006. Patients with no sphincter involvement were not included and underwent intersphincteric resection with coloanal anastomosis. CRM involvement was defined as ≤ 2 mm using a standardized pathology protocol. Data were presented as mean ± SD or as median (range). Results Seventy‐four patients (60 ± 14 years of age; body mass index = 29.7 ± 7.9 kg/m²) underwent laparoscopic APR. The distance of the tumour from the anal verge was 3.1 ± 0.93 cm. All patients had sphincter involvement. The operative time was 180 ± 73 min, and estimated blood loss was 269 ± 149 ml. There were no conversions and no postoperative mortality. The adverse event rate was 11%. There were two reoperations and three readmissions. Seventy‐one patients had a T3 tumour and three patients had a T4 tumour. The median tumour size was 3.1 (range, 0–10) × 3 (range, 0–8.5) × 2 (range, 0–3.6) cm, and 26 (range, 3–41) lymph nodes were harvested. The median CRM was 7 (range, 1–11) mm. This was localized at the waist of the specimen in 12 (16.2%) of patients. Adjuvant therapy was given to 92% and 97% of patients with an involved and an uninvolved CRM, respectively. At 50 ± 27 months of follow up of 73 patients, 12 had CRM involvement and had a significantly decreased cancer‐specific survival (log rank test, P = 0.002). Conclusion Laparoscopic APR resulted in CRM involvement in 16.2% of patients with rectal cancer.     

Combined radical prostatectomy and abdominoperineal resection for locally invasive rectal cancer

INTRODUCTION

An infiltration of urological organs is found in 5–10% of patients with colorectal carcinoma. Total pelvic exenteration is the standard procedure for locally advanced rectal cancer. In selected patients with rectal cancer involving the prostate or seminal vesicles, the bladder can be preserved and en bloc radical prostatectomy with abdominoperineal rectal resection can be performed. We report two patients who treated with this combined approach.

PRESENTATION OF CASE

Two patients with symptoms of rectal bleeding and pelvic pain were investigated. Colonoscopy demonstrated a tumor in the lower rectum. Biopsies revealed adenocarcinoma. Both pelvic MRI and endorectal ultrasound showed tumors that invaded the prostate and the seminal vesicles directly but without invasion of the bladder. After neoadjuvant chemoradiation, combined radical prostatectomy and abdominoperineal amputation was performed. None has developed local recurrence, but one of them was operated on for a single lung metastasis. After a follow-up of 28 and 20 months, respectively, the patients are alive without evidence of local recurrence or distant disease.

DISCUSSION

This procedure obviates the need for urinary diversion without compromising the local tumor control. Intraoperative and postoperative diagnostic difficulties, and clinical aspects in relation to postoperative anastomotic leak and survival of patients are discussed.

CONCLUSION

En bloc radical prostatectomy and proctosigmoidectomy is feasible in selected patients with rectal cancer and invasion limited to the prostate or seminal vesicles because it provides good local tumor control and significantly improves the patient''s quality of life in comparison to total pelvic exenteration.     

Examination of outcome following abdominoperineal resection for adenocarcinoma in Oxford

Aim Abdominoperineal resection (APR) has been shown to have poor outcomes compared with anterior resection (AR) in the treatment of rectal cancer. We compared APR outcomes with those for low AR. Method Lower third rectal cancers treated at the John Radcliffe Hospital with APR and low AR were examined using a prospectively collected database augmented with review of patient records. For all cases (APR and low AR), a range of patient, cancer and outcome data were collected. A selected group was created on the basis of exclusions. Outcomes for the global and selected APR and low AR groups were compared using the Kaplan–Meier method. CRM+ve and CRM?ve APR cases were compared. Results Between 1994 and 2003, 70 APR and 93 low AR were performed. After exclusions, 42 APR and 81 low AR remained. Median follow‐up was 4.8 years. Five year survival for the APR group was significantly worse than for the low AR group. The APR group showed significantly fewer T0 cancers and significantly more T3 cancers. CRM R1 involvement was significantly higher for the APR group. The CRM+ve APR group contained significantly more later stage cancers, more defective resection specimens, more abscesses and fistulas and was associated with more local recurrence. Conclusions These data showed that APR led to worse results than low AR in terms of overall survival and circumferential margin involvement, but that the cancers treated with APR tended to be more locally advanced.     

经腹-会阴联合直肠癌根治术后经腹膜外造口对患者旁疝与排便功能的影响

目的探讨经腹-会阴联合直肠癌根治术后经腹膜外造口对患者旁疝与排便功能的影响。 方法选择2016年1月至2017年6月,广元市中心医院行经腹-会阴联合直肠癌根治术78例患者的临床资料。其中经腹膜外造口者40例为观察组,经腹膜内造口者38例为对照组,2组患者均于围手术期接受全程护理。比较2组手术指标、术后并发症发生情况及排便功能。 结果观察组术中出血量、住院时间分别为（104.24±39.08）ml和（15.62±3.10）d,与对照组（120.46±47.35）ml和（17.20±2.95）d,差异有统计学意义（P<0.05）;观察组手术时间、造口时间、术后切口愈合时间分别为（233.12±40.50）min、（21.87±9.23）min和（7.31±0.28）d,与对照组（231.38±39.04）min、（20.95±9.14）min和（7.05±0.34）d,差异无统计学意义（P>0.05）。观察组排便功能优良率显著高于对照组,差异有统计学意义（67.50% vs 34.21%,P<0.05）。观察组造口旁疝的发生率显著低于对照组,差异有统计学意义（2.50% vs 18.42%,P<0.05）;但2组间造口出血、造口水肿、造口回缩或脱垂等发生率比较,差异无统计学意义（P>0.05）。 结论经腹-会阴联合直肠癌根治术后经腹膜外造口可显著降低术后造口旁疝的发生率,促进其排便功能的恢复,整体疗效优于经腹膜内造口。     

Quality of life after surgery for rectal cancer with special reference to pelvic floor dysfunction

Aim Conventional outcomes such as survival, tumour recurrence and complication rates after surgery for rectal cancer have been rigorously assessed, but the importance of maintaining quality of life (QOL) after surgery for rectal cancer has received less attention. The aim of the current study was to analyse QOL and the occurrence of pelvic dysfunction after the surgical treatment of rectal cancer. Method Between May 2005 and May 2008, 150 patients with rectal cancer underwent abdominoperineal resection (APR) or anterior resection (AR). Seventy‐four answered two preoperative questionnaires. At a follow up of 1 year, 65 were alive without sign of recurrence and answered the same questionnaires: (a) validated RAND 36‐item health survey QOL questionnaire; and (b) self‐administered disease‐related questionnaire with special reference to anorectal and urogenital function. Results The postoperative general QOL was similar after surgery, and mental functioning was better (P < 0.001). Problems with physical functions were associated with anal dysfunction after AR (P < 0.001) and problems with social functioning were associated with urinary dysfunction (P = 0.038). At 1 year after surgery, urinary incontinence was worse (P = 0.026) after all operations, and the incidence of dysuria was higher after APR than AR (P = 0.001). Male sexual function also worsened (P = 0.060). Anorectal dysfunction caused more inconvenience among patients who underwent AR (P = 0.028). Preoperative radiation was associated with postoperative ejaculation problems (P = 0.028) and anal incontinence (P = 0.012). Conclusion Factors affecting QOL and pelvic floor function should be taken into account when making treatment decisions in rectal cancer.     

Surgical treatment of lower rectal cancer with sphincter preservation using handsewn coloanal anastomosis

The present study was designed to evaluate the technical feasibility and oncologic results of performing handsewn coloanal anastomosis (CAA). A total of 46 patients treated for lower rectal cancer using CAA were retrospectively studied, and the oncologic results were compared with those of 105 patients treated with abdominoperineal resection (APR). CAA was performed in patients who had both good mobility of the tumor and a distal clearance margin of more than 1.0 cm. No significant difference was noted in the mortality rates following the two operations (CAA 2.2% vs APR 1.9%). Pelvic recurrence was detected in two patients (4.5%) after CAA and in six patients (7.2%) after APR. The 5-year survival rate after CAA was 79.2% and that after APR was 72.6%. No significant difference was noted in the incidence of pelvic recurrence or the survival rates between the two operations. These results show that CAA could be an excellent reconstructive option in the treatment of lower rectal carcinoma for selected patients.     

低位直肠癌经肛提肌外腹会阴联合切除术与传统术式的疗效比较

目的比较腹会阴直肠癌根治术与传统腹会阴直肠癌根治术(APR)治疗低位直肠癌的并发症及短期手术效果。方法回顾性分析2012年1月至2015年9月54例行低位进展期直肠癌手术病人的临床资料,20例病人接受传统APR手术(APR组),34例接受肛提肌外腹会阴直肠癌根治术(ELAPE组)。结果与传统APR组比较,ELAPE组术中出血量较少,术中标本穿孔率及环周切缘阳性率低,差异有统计学意义(P0.05);与传统APR比较,ELAPE组术后会阴切口并发症发生率、尿潴留发生率更高,手术时间较长,差异有统计学意义(P0.05)。经过短期随访,ELAPE组1例出现复发,无死亡病例;传统APR组盆底复发1例,死亡1例。两组局部复发率及死亡率比较差异无统计学意义(P0.05)。结论 ELAPE手术虽然在一定程度上增加了会阴区相关并发症的发生率,但其明显降低了术中直肠穿孔率和术后标本环周切缘(CRM)阳性率,减少术中出血量,提高了手术根治效果,具有非常重要的临床价值。     

Hand-sewn coloanal anastomosis for distal rectal cancer: Long-term clinical outcomes

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n = 1), and anal stenosis (n = 7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.     

Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases

Aim

The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two‐centre study was to determine the clinical success and morbidity after redo CAA.

Method

This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short‐ and long‐term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow‐up.

Results

A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8–27]. The median duration of follow‐up was 27 months (IQR 17–36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2–4) per patient. At the end of follow‐up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004–0.122).

Conclusion

Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.     

Function after intersphincteric resection for low rectal cancer and its influence on quality of life

Aim The aim of the study was to investigate function and quality of life after different types of intersphincteric resection (ISR). Method Between January 2006 and February 2008, 45 patients (34 men and 11 women) with distal third rectal cancer underwent curative ISR. Function was evaluated using the Memorial Sloan Kettering Cancer Center bowel function questionnaire and Wexner score, anal manometry and measurements of rectal capacity were also performed. Quality of life was assessed using the Serbian version of the European Organisation for Research and Treatment of Cancer, quality of life questionnaire (EORTC QLQ‐C30) and the translated version of the fecal incontinence quality of life scale (FIQL). Results There were no postoperative deaths. Partial ISR was performed in 22 (48.9%) patients, subtotal ISR was performed in 19 (42.2%) patients and total ISR was performed in four (8.9%) patients. Anastomotic leakage occurred in nine (20%) patients. Five (11.1%) of 45 patients had major (complete) incontinence and a further six (13.3%) patients had continuing frequent faecal leakage 12 months after ileostomy reversal. There was no significant difference in quality of life between the groups in the EORTC QLQ‐C30 scale, but this was significantly altered by internal anal sphincter resection in two of the FIQL scales (coping/behaviour and depression/self‐perception). Conclusion Although ISR does not affect quality of life in general, the extent of internal anal sphincter resection has a negative impact on symptom‐specific quality of life owing to faecal incontinence.     

低位直肠腺癌保肛手术的临床病理学分析

目的 探讨低位直肠腺癌全直肠切除结肠肛门吻合术后远端肠壁内肿瘤扩散的病理改变。方法 将55例术后患者的标本进行组织学分析。结果 局部复发的因素是:①切缘肿瘤残留;②肿瘤浸润直肠的深度;③淋巴结转移有关。结论直肠肿瘤远侧端切除的长度与局部复发密切相关。     

A systematic review and meta‐analysis of randomized and non‐randomized studies comparing laparoscopic and open abdominoperineal resection for rectal cancer

Aim  Evidence supporting the role of laparoscopy in abdominoperineal resection (APR) is limited. This study compared the short‐term and long‐term outcomes and complications associated with open and laparoscopic APR. Method  The Medline, Cochrane and Embase databases were searched for publications comparing open and laparoscopic APR. The rates of local and distant recurrence of rectal cancer were compared as the primary end‐point. The occurrence of complications related to the two procedures was studied as the secondary end‐point. The adequacy of cancer resection and postoperative recovery were also compared in a secondary analysis. Combined and separate analyses were performed for randomized and non‐randomized studies. Results  Eight publications comparing open and laparoscopic APR were identified. The rates of local and distant disease recurrence were lower after laparoscopic surgery compared with open APR (odds ratio 2.736 and 1.994, 95% confidence interval 1.137–6.584 and 1.062–3.742, P = 0.025 and P =0.032, respectively). Early postoperative complications were fewer after laparoscopic APR (OR 2.159, 95% CI 1.426–3.269, P = 0.000). No significant benefit of either technique was observed in the secondary analysis. Conclusion  The long‐term oncological benefits of laparoscopic APR are not convincingly superior to open surgery and need further validation. The laparoscopic approach is apparently associated with fewer postoperative complications, yet its role in improving the short‐term outcomes is uncertain.     

Laparoscopic ultralow anterior resection versus laparoscopic pull-through with coloanal anastomosis for rectal cancers: a comparative study

Background

Ultralow anterior resection for mid and distal rectal cancers has been reported routinely performed using either a laparoscopic ultralow anterior resection (LAR) or laparoscopic pull-through with coloanal anastomosis (LPT). This study evaluated the postoperative and functional outcomes.

Methods

Between January 2007 and December 2008, 40 consecutive patients had laparoscopic surgery for rectal cancers. The data were prospectively collected.

Results

There were 21 patients (21 men; mean age 61.2 ± 3.2 years standard error of the mean [SEM]) in the LAR group and 19 (16 men; mean age 61.4 ± 2.4 years SEM) in the LPT group. Tumor characteristics, adjuvant therapy given, mean follow-up (overall 33.5 ± 1.4 months SEM), intraoperative time, blood loss, mesorectum quality, conversion rate (LAR n = 2, LPT n = 1), pain score, time for ileostomy to function, subsequent incontinence scores, and complication rates (LAR n = 7, LPT n = 9) were not different between groups, but benign anastomotic strictures were higher after LPT (n = 4, LAR n = 0, P = .042). The latter was associated with chemoradiotherapy (P = .015). There were 2 systemic cancer recurrences both in the LPT group but no local recurrences to date.

Conclusions

The LAR technique may have less risk of anastomotic strictures, particularly with adjuvant therapy. LPT may be considered selectively for a bulky distal rectal tumor in a small pelvis with comparable functional results.     

Miles术后会阴部切口感染的危险因素分析及预防对策

目的探讨Miles术后会阴部切口感染的危险因素,并为术后会阴部切口感染提供有价值的预防措施。方法收集2013年1月至2015年12月在扬州大学附属泰兴医院就诊且行Miles手术的61例直肠癌病人临床资料,根据是否术前用洗必泰清洗会阴部、术中麻醉消毒后即刻封闭肛门这一干预措施分为观察组和对照组,分析比较两组术后会阴部切口感染发生率及其他相关临床指标是否有差异;根据术后是否发生切口感染把研究对象分为感染组及非感染组,分析术后会阴部切口感染的危险因素。结果两组总体会阴部切口感染率为19.7%(12/61),观察组的会阴部切口感染发生率与对照组相比(6.5%比33.3%)降低(P0.05),并且术后抗生素使用时间及住院时间均减少(P0.05)。单因素分析显示,Miles术后会阴部切口感染组与未感染组在干预措施、合并糖尿病、输血、浸润深度、肿瘤分期方面比较,差异均有统计学意义(均P0.05);多因素分析显示未使用干预措施、合并糖尿病、输血、肿瘤分期(Ⅳ期)是Miles术后会阴部切口感染的危险因素;干预措施是预防术后会阴部切口感染的保护性措施。结论未使用干预措施、合并糖尿病、输血、肿瘤分期是Miles术后会阴部切口感染的危险因素,而术前洗必泰清洗会阴部、术中麻醉消毒后即刻封闭肛门能降低术后切口感染发生率,是术后会阴部切口感染的有效预防措施。