Abdominoperineal resection for locally recurrent rectal cancer

To evaluate whether surgical resection confers survival advantages in selected patients with resectable locally recurrent rectal cancer, data on 430 patients who underwent R0 resection for primary rectal cancer were prospectively collected over a 14-year period. Resection of recurrent disease was considered R0 when all cancer tissue was resected with microscopically tumor-free surgical margins. Microscopic evidence of disease at resection margins was considered an R1 resection. Recurrent disease was detected in 158 of 430 patients. Local recurrence was found in 91 patients, including (79%) with resection-site relapse only. These patients were considered for surgery unless defined unresectability criteria were met. A total of 35 patients who had abdominoperineal excision following anterior resection were studied retrospectively. Mortality associated with the procedure was 3% and morbidity was 20%. The resection was R0 in 12 patients, while microscopic margins were involved in 23 patients. 10 patients had extended resection of one or several adjacent organs Median operating time and blood loss were 250 min and 500 ml respectively. Median hospital stay was 25 days. 21/23 R1 patients received postoperative radiotherapy. Return to normal activity occurred at 8.2 (SD 4.2) weeks. No patients were lost to follow-up. Overall median survival was 26.4 months; 5-year survival was 25.4%. In spite of several survival predictors at univariate analysis, R0 or R1 resection was the only independent predictor of survival at multivariate analysis (add ratio 112.7, 95% CI 3.6–3500, p=0.007). Median survival rate was not reached at the 146-month follow-up in patients with R0 resection. Median survival rate was 16.6 months in patients with R1 resection. In conclusion, uninvolved microscopic margins produce long-term survivors after surgical resection for locally recurrent rectal cancer. Received: 24 June 2001 / Accepted: 13 July 2001     

Outcomes for Abdominoperineal Resections Are Not Worse Than Those of Anterior Resections

Purpose Local recurrence and cure rates following abdominoperineal resections have been reported to be much worse than sphincter-preserving anterior resections. We compared the oncologic outcomes of patients treated by abdominoperineal resections with those following sphincter-preserving anterior resections. Methods The medical records of patients who underwent radical rectal resection for rectal carcinoma at the Colorectal Surgery Department, Singapore General Hospital, during the period from April 1989 to April 2002 were reviewed. A total of 791 cases were studied. Operative procedures were classified as either abdominoperineal resections or anterior resections with either straight or pouch anastomosis. Total mesorectal excision was routinely performed for carcinomas of the lower middle and lower third of the rectum. Sentinel events, including local and systemic recurrences or morbidity and mortality, were tracked prospectively. Results There were a total of 93 abdominoperineal resections (12.1 percent), 547 anterior resections with straight anastomoses (71 percent), and 130 anterior resections with pouch anastomoses (16.9 percent). Postoperative mortality was 2.6 percent and postoperative morbidity was 13.6 percent with an overall anastomotic leakage rate of 2.5 percent. The cumulative five-year local recurrence rate was 5.4 percent for abdominoperineal resections, 3.6 percent for anterior resections with straight anastomoses, and 3.8 percent for anterior resections with pouch anastomoses (P = 0.73 by log-rank test). The median time to local recurrence also did not differ significantly between the different procedures (abdominoperineal resections, 17 months, anterior resections with straight anastomoses, 18 months, anterior resections with pouch anastomoses, 13 months). Independent predictors for local recurrence included advanced tumor stage, tumor depth, and poorly differentiated tumors. The five-year cancer-specific survival was 70 percent. The type of anastomosis did not influence disease-free survival with median disease-free survival for patients who underwent abdominoperineal resections being 100 months, survival of anterior resections with straight anastomoses being 135 months, and survival of anterior resections with pouch anastomoses being 121 months (P = 0.33 by log-rank test). The independent factors for poor survival were age greater than 65 years, advanced tumor stage, tumor depth, and poorly differentiated tumors. Conclusion Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections. Reprints are not available.     

Local tumor recurrence after curative resection for rectal cancer

Local tumor recurrence rates after curative rectal cancer surgery with the end-to-end anastomosis stapler (EEA^®) are reportedly high. Therefore, a retrospective review in ten Yale-affiliated hospitals was undertaken to establish the outcome of surgical resection for rectal cancer in this patient population. Of those 373 patients who had had curative resections, 192 (52 percent) were abdominoperineal resections (APR); 105 patients (28 percent) had restorative resections with sutured anastomoses, and the EEA stapler was used in 76 patients (20 percent). There was an equal distribution of tumors in the various Dukes' stages in all three procedures. Local tumor recurrence was: APR 19 percent, SUT 17 percent, and EEA 24 percent, but local tumor recurrence was more frequent after EEA than APR for tumors 7 to 10 cm from the anal verge (32 vs. 13 percent, respectively,P<0.05), and the time to recurrence was least in EEA patients. It is concluded that local tumor recurrence is higher than expected for all three procedures and that the EEA stapler was associated with a greater risk of local tumor recurrence. These findings are attributed to surgeon-related technical operative factors rather than to the nature of the tumors themselves.     

Laparoscopicvs. open abdominoperineal resection for cancer

PURPOSE: The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer. METHODS: Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow-up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent). RESULTS: Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24vs. 8 percent;P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7vs. 12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan-Meier curves, with median follow-up of 19 and 24 months, respectively (P=0.22; log rank). CONCLUSION: Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long-term outcome of cancer treatment.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Surgery for local pelvic recurrence after resection of rectal cancer

This retrospective study evaluated outcome with regard to procedure, local control, and survival after curative surgical resection with and without preoperative radiotherapy for local pelvic recurrence. A total of 58 consecutive patients with local pelvic recurrence of rectal cancer after previous curative resection for primary tumors were reviewed. Of these, 36 underwent both initial resection and follow-up in our department; the remaining 22 had initial surgery and follow-up elsewhere. Of the 58 patients 27 underwent curative re-resection, 9 had palliative resection, and 22 were treated by conservative therapy. Among the 27 patients with curative resection 17 received preoperative radiotherapy (40 Gy) plus surgery and 10 surgery only. No patients were lost to follow-up; median follow-up time was 36.3 months. The overall rate of curative resection was 46.6%: 55.6% in our own follow-up group and 31.8% in the others. With regard to surgical procedure, abdominoperineal resection (APR) with or without sacral resection was standard following previous low anterior resection, and total pelvic exenteration (TPE) with or without sacral resection was common following APR. There was a high incidence of morbidity (71.4%) after TPE. Re-recurrence was observed in 12 (44.4%) after curative re-resection. There was local re-recurrence in 6 (22.2%). The local re-recurrence rate was 11.8% (n = 2) with radiotherapy plus surgery, and 40.0% (n = 4) with surgery alone. The estimated 5-year survival following curative re-resection was 45.6% (61.2% with radiotherapy plus surgery, 29.6% with surgery alone). Both survival and local control with radiotherapy plus surgery tended to be better than with surgery alone. Thus, in selected patients pelvic local recurrence of rectal cancer can be re-resected curably by APR or TPE (with or without sacral resection) combined with preoperative radiotherapy. Accepted: 10 October 1997     

Abdominoperineal excision following preoperative radiotherapy for rectal cancer: Unfavorable prognosis even with negative circumferential resection margin

AIM: To evaluate whether an abdominoperineal excision (APE) is associated with increased local recurrence (LR) and shortened disease-free survival (DFS) in mid-low rectal cancer with a negative circumferential resection margin (CRM).METHODS: 283 consecutive cases of mid-low rectal cancer underwent preoperative 30 Gy/10 F radiotherapy and surgery in Peking University Cancer Hospital between August 2003 and August 2009. Patients with positive CRM and intraoperative distant metastasis were precluded according to exclusion criteria. Survival analyses were performed in patients with APE or non-APE procedures.RESULTS: 256 of the 283 (90.5%) cases were enrolled in the analysis, including 78 (30.5%) and 178 (69.5%) cases who received APE and non-APE procedures. Fewer female patients (P = 0.016), lower level of tumor (P = 0.000) and higher body mass index (P = 0.006) were found in the APE group. On univariate analysis, the APE group had a higher LR rate (5.1% vs 1.1%, P = 0.036) and decreased DFS (73.1% vs 83.4%, P = 0.021). On multivariate analysis, APE procedure was also an independent risk factor for LR (HR = 5.960, 1.085-32.728, P = 0.040) and decreased DFS (HR = 2.304, 1.298-4.092, P = 0.004). In stratified analysis for lower rectal cancer, APE procedure was still an independent risk factor for higher LR rate (5.6% vs 0%, P = 0.024) and shortened DFS (91.5% vs 73.6%, P = 0.002).CONCLUSION: Following preoperative 30 Gy/10 F radiotherapy, APE procedure was still a predictor for LR and decreased DFS even with negative CRM. More intensive preoperative treatment should be planned for the candidates who are scheduled to receive APE with optimal imaging assessment.     

Oncologic Results Following Abdominoperineal Resection for Adenocarcinoma of the Low Rectum

PURPOSE: The role of abdominoperineal resection for rectal cancer has changed because of advances in sphincter-preserving surgery. Our aim was to evaluate the results of this operation in the five-year period following introduction of the concept of total mesorectal excision METHODS: Data on all patients undergoing abdominoperineal resection for very low rectal cancer between 1992 and 1997 were collected prospectively. All patients had had total mesorectal excision. Curative resection was defined as absence of macroscopic disease after resection and local recurrence as any infiltration or tumor identified in the pelvis, alone or combined with distant disease. Survival and local recurrence rates were calculated using the Kaplan-Meier method and log-rank analysis. RESULTS: Of 165 abdominoperineal resections performed, 106 were for primary adenocarcinoma of the rectum. The male:female ratio was 50:56, with a median age of 65 (range, 33–85) years. There was one postoperative death. Twenty-seven patients received short-course preoperative radiotherapy (25 Gy over 1 week), whereas 22 had a longer course, with concomitant chemotherapy in 2. Postoperative chemotherapy was administered in 29, postoperative radiotherapy in 4, and combined therapy in 8. After curative resection (n = 91), survival at five years was 76 percent and differed significantly by stage. Recurrence at any site was 7 percent (3/34) for Stage I, 27 percent (6/26) for Stage II, and 53 percent (16/31) for Stage III. Nine patients presented with local recurrence, with an overall rate at five years of 10 percent. Isolated locale recurrence was observed in only 5 percent of patients CONCLUSIONS: After abdominoperineal resection and total mesorectal excision, good rates of local control may be achieved provided surgical technique is meticulous.     

腹腔镜腹会阴联合切除术腹膜外结肠造口对比腹膜内造口治疗直肠癌的Meta分析

目的比较直肠癌行腹腔镜腹会阴联合切除术（LAPR）腹膜外结肠造口与腹膜内结肠造口的安全性与有效性,并确定直肠癌永久性结肠造口最为合适的造口方式。 方法检索Pubmed、Embase、The Cochrane Library、Web of Science、中国知网以及万方数据库等中英文数据库,收集2008年10月至2020年3月国内外公开发表的有关比较LAPR腹膜外造口与腹膜内造口治疗直肠癌的临床研究,由两位研究者按照纳入与排除标准筛选符合条件的文献,非随机对照研究采用Newcastle-Ottawa Scale（NOS）量表评价文献质量,评分>5分的研究纳入Meta分析,随机对照研究采用Jadad量表评估。提取文献基本信息及相关结局指标,数据采用RevMan5.3软件进行Meta分析。 结果最终纳入14篇文献,其中9篇临床对照研究,5篇随机对照研究,共计1 210例患者。其中腹膜外造口组594例,腹膜内造口组616例,Meta分析结果显示,与腹腔镜腹膜内造口相比,腹腔镜腹膜外造口组造口旁疝发生率（OR=0.14,95%CI：0.08~0.25;P<0.00001）,造口脱垂发生率（OR=0.15,95%CI：0.06~0.37;P<0.0001）,造口回缩发生率（OR=0.24,95%CI：0.09~0.63;P=0.004）均明显降低;术后住院时间缩短（MD=-0.82,95%CI：-0.97~-0.68;P<0.00001）,术后首次排气时间提前（MD=-0.71,95%CI：-0.88~-0.54;P<0.00001）,更容易获得排便感（OR=9.67,95%CI：4.40~21.23;P<0.00001）,但造口水肿发生率明显升高（OR=1.81,95%CI：1.13~2.92;P=0.01）,而两组造口狭窄发生率（OR=0.62,95%CI：0.25~1.50;P=0.29）、造口感染发生率（OR=0.57,95%CI：0.29~1.12;P=0.10）以及造口时间（MD=-0.94,95%CI：-5.69~3.81;P=0.70）的差异均无统计学意义。 结论LAPR腹膜外造口能明显降低造口相关并发症的发生率,加速患者康复,更容易获得排便感,具有一定的安全性和有效性,建议直肠癌LAPR永久性结肠造口首选腹膜外造口方式。     

Omentoplasty in Abdominoperineal Resection: A Review of the Literature Using a Systematic Approach

Purpose Abdominoperineal resection is associated with considerable morbidity, in particular, the perineal wound. Omentoplasty has been proposed as a means of reducing the perineal complication rate after abdominoperineal resection. This study was designed to assess the available evidence for omentoplasty in abdominoperineal resection. Methods A MEDLINE search from January 1970 to July 2005 was performed to locate English language articles relating to omentoplasty in abdominoperineal resection. Manual search via reference lists identified additional articles. Articles reporting results from at least ten patients in whom abdominoperineal resection with an omentoplasty was performed were considered. All included reports were reviewed by using a predetermined protocol. Results Among the ten reports identified, no randomized trials, four studies with control groups, and six case series were found. Primary healing was the outcome measure that was most consistently reported in the different articles. Most authors reported positive results after omentoplasty, and one study showed significant improvement in perineal healing rate at six months. Significant reduction in sinus formation and wound dehiscence also was reported. Only few complications related to the omentoplasty, none of which was fatal, were reported. Conclusions Although results from the studies included in this review indicate that there may be benefits from including an omentoplasty when performing an abdominoperineal resection, the lack of randomized studies results in only weak evidence. Supported by the Public Health and Medical Service Committee of Stockholm County Council. Presented at the meeting of the Swedish Surgical Society, ?rebro, Sweden, August 21 to 25, 2006. Reprints are not available.     

Meta-analysis of short-term outcomes after laparoscopic resection for rectal cancer

Background Laparoscopic resection (LR) has become increasingly popular for the management of rectal cancer. Despite a decade of experience, the safety and efficacy of LR for rectal cancer remains to be established. This report performs a meta-analysis to compare LR with conventional open resection (CR) in patients with rectal cancer.Methods Using a defined search strategy, studies directly comparing CR with LR for rectal cancer were identified. The data for patients with rectal cancer treated with both approaches were extracted and used in our meta-analysis. Open surgery and laparoscopic surgery were compared in terms of postoperative mortality, morbidity, complications, oncological clearance, operating time, and time before recovery to a normal diet.Results Compared with CR, LR is associated with lower morbidity rates [OR 0.63 (0.41, 1.96) P=0.03], longer operating times [weighted mean difference 1.59 (1.20, 1.98) P<0.00001], similar mortality rates, wound healing disorder rates, urinary disorder rates, cardiopulmony disease rates, all leakage rates, all abscess rates and a positive rate of margin.Conclusion LR is associated with less postoperative morbidity, but longer operation time. A prospective randomized controlled trial is warranted to fully investigate these and other outcome measures.     

Primary Perineal Wound Closure After Preoperative Radiotherapy and Abdominoperineal Resection has a High Incidence of Wound Failure

PURPOSE Neoadjuvant radiation therapy has been used increasingly to downstage rectal cancer and decrease local recurrence. Despite its efficacy, preoperative radiation therapy may inhibit healing and contribute to wound complications. This study was designed to evaluate perineal wound complications after abdominoperineal resection.METHODS The clinical records of a consecutive series of patients who underwent abdominoperineal resection for rectal carcinoma between 1988 and 2002 were reviewed. Demographic data, disease stage, and use of preoperative radiation therapy were recorded. Major wound complications included delayed wound healing (>1 month), wound infection requiring drainage/debridement, or reoperation.RESULTS A total of 160 patients underwent abdominoperineal resection with primary closure of the perineal wound (mean age, 63 ± 12 years); 117 (73 percent) patients received preoperative radiation therapy; 114 received radiation therapy for rectal cancer (radiation therapy + chemotherapy = 107, radiation therapy alone = 7); 3 received radiation therapy for other pelvic malignancies. Median radiation dose was 5,040 (range, 900–5,400) cGY. Overall wound complication rate was 41 percent. Major wound complication rate was 35 percent. Delayed healing was the most common complication (24 percent), followed by infection (10 percent). Radiation therapy increased the risk of any wound complication (47 vs. 23 percent; P = 0.005), risk of a major wound complication (41 vs. 19 percent; P = 0.021), and risk of infection (14 vs. 0 percent; P = 0.015). Risk of wound complications did not correlate with age, gender, disease stage, smoking, or diabetes.CONCLUSIONS Wound complications are frequent after abdominoperineal resection and primary closure of the perineum. Preoperative radiation therapy doubles the rate of total and major perineal wound complications. Alternatives to primary perineal closure should be considered, particularly after radiation therapy.Read at meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Male sexual function after abdominoperineal resection for rectal cancer

In a series of 26 male patients undergoing abdominoperineal resection of the rectum for malignant disease, a detailed history of sexual function was obtained, using a questionnaire before and 12 months after the operation. The overall incidence of sexual dysfunction was 61.5 per cent, total and partial erectile impotence being, respectively, both 27 per cent. Taking age into account, among men of the youngest age group (41–48 yrs), incidence of complete and partial erectile impotence was 14 per cent. In the middle age group (49–57 yrs), 22 per cent reported total and 33 per cent reported partial erectile impotence, whereas in patients of the oldest group (58–65 yrs), total erectile impotence was present in 40 per cent and partial in an additional 30 per cent. The extent of the disease (Dukes' stage) was found to be of no value as a prognostic index of postoperative sexual dysfunction. It is concluded that the age of the patients is the most important factor related to sexual activity after abdominoperineal resection for cancer.     

Laparoscopic vs open abdominoperineal resection in the multimodality management of low rectal cancers

AIM: To evaluate the safety and feasibility of laparoscopic abdominoperineal resection compared with the open procedure in multimodality management of rectal cancer.METHODS: A total of 106 rectal cancer patients who underwent open abdominoperineal resection(OAPR) were matched with 106 patients who underwent laparoscopic abdominoperineal resection(LAPR) in a 1 to 1 fashion, between 2009 and 2013 at Fudan University Shanghai Cancer Center. Propensity score matching was carried out based on age, gender, pathological staging of the disease and administration of neoadjuvant chemoradiation. Data regarding preoperative staging, surgical technique, pathologicalresults, postoperative recovery and complications were reviewed and compared between the LAPR and OAPR groups. Perineal closure around the stoma and pelvic floor reconstruction were performed only in OAPR, not in LAPR. Therefore, abdominoperineal resection procedure-specific surgical complications including parastomal hernia and perineal wound complications were compared between the open and laparoscopic procedure. Regular surveillance of the two cohorts was carried out to gather prognostic data. Diseasefree survival was analyzed using Kaplan-Meier estimate and log-rank test. Subgroup analysis was performed in patients with locally advanced disease treated with preoperative chemoradiation followed by surgical resection. RESULTS: No significant difference was found between the LAPR group and the OAPR group in terms of clinicopathological features. The operation time(180.8 ± 47.8 min vs 172.1 ± 49.2 min, P = 0.190), operative blood loss(93.9 ± 60.0 m L vs 88.4 ± 55.2 m L, P = 0.494), total number of retrieved lymph nodes(12.9 ± 6.9 vs 12.9 ± 5.4, P = 0.974), surgical complications(12.3% vs 15.1%, P = 0.549) and pathological characteristics were comparable between the LAPR and OAPR group, respectively. Compared with OAPR patients, LAPR patients showed significantly shorter postoperative analgesia(2.4 ± 0.7 d vs 2.7 ± 0.6 d, P 0.001), earlier first flatus(57.3 ± 7.9 h vs 63.5 ± 9.2 h, P 0.001), shorter urinary drainage time(6.5 ± 3.4 d vs 7.8 ± 1.3 d, P 0.001), and shorter postoperative admission(11.2 ± 4.7 d vs 12.6 ± 4.0 d, P = 0.014). With regard to APR-specific complications(perineal wound complications and parastomal hernia), there were no significant differences between the two groups. Similar results were found in the 26 pairs of patients administered neoadjuvant chemoradiation in subgroup analysis. During the follow-up period, no port site recurrences were observed. CONCLUSION: Laparoscopic abdominoperineal resection for multidisciplinary management of rectal cancer is safe, and is associated with earlier recovery and shorter admission time in combination with neoadjuvant chemoradiation.     

A comparison of transanal excision and endoscopic resection for early rectal cancer

AIM: To compare the outcomes of endoscopic resection with transanal excision in patients with early rectal cancer.METHODS: Thirty-two patients with early rectal cancer were treated by transanal excision or endoscopic resection between May 1999 and December 2007. The patients were regularly re-examined by means of colonoscopy and abdominal computed tomography after resection of the early rectal cancer. Complications, length of hospital-stay, disease recurrence and follow up outcomes were assessed.RESULTS: Sixteen patients were treated by endoscopic resection and 16 patients were treated by transanal excision. No significant differences were present in the baseline characteristics. The rate of complete resection in the endoscopic resection group was 93.8%, compared to 87.5% in the transanal excision group (P = 0.544). The mean length of hospital-stay in the endoscopic resection group was 2.7 ± 1.1 d, compared to 8.9 ± 2.7 d in the transanal excision group (P = 0.001). The median follow up was 15.0 mo (range 6-99). During the follow up period, there was no case of recurrent disease in either group.CONCLUSION: Endoscopic resection was a safe and effective method for the treatment of early rectal cancers and its outcomes were comparable to those of transanal excision procedures.     

直肠癌柱状经腹会阴切除术

柱状经腹会阴切除术(肛提肌外腹会阴切除术)作为直肠癌的一种新术式,较常规经腹会阴切除术可以切除更多的癌周组织,减少术中穿孔,降低环周切缘阳性率,从而达到改善预后的目的。作者在国内率先开展本术式,并创新性使用生物材料进行盆底重建,不但简化了手术,而且减少手术并发症发生的机会,使本术式更加安全可靠。笔者详细介绍了柱状腹会阴切除术操作要点和注意事项,阐述了本术式的优势和发展前景,柱状经腹会阴切除术有望成为无法保肛直肠癌患者的标准术式。     

Preoperative irradiation affects functional results after surgery for rectal cancer

PURPOSE: The Swedish Rectal Cancer Trial has unequivocally demonstrated that preoperative high-dose (5 × 5 Gy) radiotherapy reduces local failure rates and improves overall survival. This will have an impact on the primary treatment of rectal cancer. This study investigates the effect of preoperative high-dose radiotherapy on long-term bowel function in patients treated with anterior resection. METHODS: A questionnaire was answered by 92 percent (203/220) of patients who were included in the Swedish Rectal Cancer Trial and who were alive after a minimum of five years. Thirty-two patients were excluded, mainly because of postoperative stomas and dementia, which left 171 for analysis. RESULTS: Median bowel frequency per week was 20 in the irradiated group (n=84) and 10 in the surgery-alone group (n=87;P<0.001). Incontinence for loose stools (P<0.001), urgency (P<0.001), and emptying difficulties (P<0.05) were all more common after irradiation. Sensory functions such as discrimination between gas and stool and ability to safely release flatus did not, however, differ between groups. Thirty percent of the irradiated group stated that they had an impaired social life because of bowel dysfunction, compared with 10 percent of the surgery-alone group (P<0.01). CONCLUSIONS: The study indicates that high-dose radiotherapy influences long-term bowel function, thus emphasizing the need for finding predictive factors for local recurrence to exclude patients with a very high probability for cure with surgery alone and to use optimized radiation techniques.Supported by the Swedish Cancer Society (Grant 1921-B97-15XCC).Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.     

腹腔镜腹会阴联合切除术治疗低位直肠癌

目的探讨按照全直肠系膜切除(TME)原则,腹腔镜腹会阴联合切除术(Miles)治疗低位直肠癌的可行性。方法按照TME治疗原则,在腹腔镜辅助下,对14例低位直肠癌患者实施TME腹会阴联合切除术。结果14例患者均手术顺利。手术时间120～240分钟,平均180分钟．术中出血30～180ml,平均50ml;术后1～2天恢复胃肠功能并下床活动,住院5～14天,平均为6天。术后6例应用镇痛剂,无术中及术后并发症发生。结论腹腔镜腹会阴联合切除术治疗低位直肠癌,能完全达到TME要求,且创伤小、术后疼痛轻、恢复快。     

Risk factors for adverse outcome in low rectal cancer

AIM: To demonstrate the oncologic outcomes of low rectal cancer and to clarify the risk factors for survival, focusing particularly on the type of surgery performed.METHODS: Data from patients with low rectal carcinomas who underwent surgery, either sphincter-preserving surgery (SPS) or abdominoperineal resection (APR), at The First Affiliated Hospital of Sun Yat-sen University in China from August 1994 to December 2005 were retrospectively analyzed.RESULTS: Of 331 patients with low rectal cancer, 159 (48.0%) were treated with SPS. A higher incidence of positive resection margins and a higher 5-year cumulative local recurrence rate (14.7% vs 6.8%, P = 0.041) were observed in patients after APR compared to SPS. The five-year overall survival (OS) was 54.6% after APR and 66.8% after SPS (P = 0.018), and the 5-year disease-free survival (DFS) was 52.9% after APR and 65.5% after SPS (P = 0.013). In multivariate analysis, poor OS and DFS were significantly related to positive resection margins, pT3-4, and pTNM III-IV but not to the type of surgery.CONCLUSION: Despite a higher rate of positive resection margins after APR, the type of surgery was not identified as an independent risk factor for survival.     

Anastomotic recurrence after sphincter-saving resection for rectal cancer

A retrospective study of anastomotic recurrence after sphincter-saving resection for rectal cancer is presented. During the 21 years from 1962 to 1982, 273 patients with rectal cancer underwent sphincter-saving resection and 30 (11 percent) of them had anastomotic recurrences. Computer analysis of 69 variables was undertaken to identify factors contributing to the anastomotic recurrence, with special reference to the length of distal clearance of the bowel. There was no significant correlation between the incidence of recurrence and the length of distal clearance of the bowel, if the latter was over 2 cm. There appears to be justification for carrying out a curative sphincter-saving operation for cases in which more than a 2-cm distal margin can be afforded. However, for cancers of the infiltrating type, annular growths, invasion to adjacent organs or mucinous features, a more extensive distal clearance of the bowel is necessary, and the Miles operation should be performed.     

Long-term oncologic results of patients with distal rectal cancer treated by local excision with or without adjuvant treatment

Aim The aim of this study is to review long-term oncologic results of local excision (LE) and to investigate the validity and feasibility of LE as a treatment option for distal rectal cancer. Materials and methods Seventy-six patients who underwent LE for distal rectal adenocarcinoma with curative intent from 1991 to 2000 at Severance Hospital Yonsei University Medical Center, Seoul, Korea were enrolled in this study. Results Preoperative transrectal ultrasonography revealed 3 cases of uT0, 55 cases of uT1 and 18 cases of uT2. Postoperative pathologic examination revealed 10 cases of pT0 (where no residual cancer cells remained), 11 cases of pTis, 37 cases of pT1, 16 cases of pT2, and 2 cases of pT3. Eleven out of 37 patients with pT1 tumors received adjuvant radiation therapy. Among 16 patients with pT2 tumor, 7 undertook salvage operation and 8 received adjuvant therapy. The median follow-up period was 84.9 months. Local recurrence was observed in six patients. The 5-year local recurrence-free survival rate (LFS) was 89.4% in the pT1 group and 75.0% in the pT2 group (p = 0.012). Among the patients with pT1 cancer, those who received adjuvant radiation therapy demonstrated a 5-year LFS of 100%, compared to those who did not, 76.0% (p = 0.038). Conclusion Our results imply a potential role of LE and adjuvant radiation as an option for the treatment of distal rectal cancer, and that even for pT1 carcinoma, LE alone might not be a valid modality.