Neoadjuvant therapy for rectal cancer: histologic response of the primary tumor predicts nodal status

PURPOSE

This study was designed to compare histologic T and N stages in patients with rectal adenocarcinoma undergoing various neoadjuvant radiotherapy regimens and proctectomy, in an attempt to determine if final histologic stage of the mural tumor predicts nodal status.

METHODS

Data were collected from computerized databases at two institutions on 649 consecutive patients who underwent neoadjuvant radiotherapy or chemoradiotherapy and proctectomy for primary adenocarcinoma of the rectum from 1990 to 2002.

RESULTS

Five patients were excluded because of incomplete pathology data sets, leaving a study population of 644. Patients underwent neoadjuvant radiotherapy alone (2000 cGy in 5 fractions, n = 191; or 4500 cGy in 25 fractions, n = 259) or chemoradiation (4500 cGy in 25 fractions with concurrent 5-fluorouracil, n = 194). Histologic stage of the remaining mural tumor (ypT) correlated with nodal status (ypN). Lymph nodes harboring metastatic tumor were found in 1 of 42 (2 percent) ypT0 patients, 2 of 45 (4 percent) ypT1 patients, 43 of 186 (23 percent) ypT2 patients, 158 of 338 (47 percent) ypT3 patients, and 16 of 33 (48 percent) ypT4 patients ( P < 0.001, chi-squared test). The probability of finding ypN+ disease was 3 of 87 (3 percent) in patients with ypT0-1 residual primary tumors vs. 220 of 557 (39 percent) in patients with ypT2-4 residual primary tumors ( P < 0.0001; Fisher's exact test).

CONCLUSIONS

Nodal metastases are rare in patients whose mural tumor burden shrinks to ypT0-1 after neoadjuvant radiotherapy. If transanal excision is offered to select patients with distal rectal cancer, it is reasonable to select those who have an excellent clinical response to neoadjuvant therapy for transanal excision, and then reserve proctectomy for patients proven to have residual ypT2-4 disease.

Fibrin glue treatment of complex anal fistulas has low success rate

PURPOSE

Fibrin glue has been used to treat anal fistulas in an attempt to avoid more radical surgical intervention. Reported success rates vary widely. The purpose of this study was to review the use of fibrin glue in the management of complex anal fistulas at a tertiary referral center.

METHODS

This study was designed as a retrospective review of all patients treated with fibrin glue injection for complex anal fistulas in the Section of Colon and Rectal Surgery, Washington University School of Medicine/Barnes-Jewish Hospital. Demographics, previous treatment, operative information, and early follow-up were obtained from the patients' medical records. Phone interviews were conducted to determine successful healing or recurrence of fistulas requiring further treatment. Statistical analysis was by Fisher's exact test. The institutional review board approved the study.

RESULTS

A total of 42 patients (19 males; median age, 44 (range, 20-76) years) were treated between 1999 and 2002. Three patients were lost to follow-up and were excluded from the study. Etiology of fistulas were cryptoglandular (n = 22), Crohn's disease (n = 13), or coloanal and ileal pouch-anal anastomotic (n = 4). Fistulas were classified as deep transsphincteric (n = 33), superficial transsphincteric (n = 1), supralevator (n = 2), or rectovaginal (n = 3). Initially, most patients had "closure" of the fistula but recrudescence was common. Durable healing was only achieved in 31 percent (12/39). Healing rates by etiology were cryptoglandular 23 percent (5/22), Crohn's disease 31 percent (4/13), and ileal pouch-anal anastomotic 75 percent (3/4; P = 0.14). Success rates by classification were deep transsphincteric 33 percent (11/33), superficial transsphincteric 0 percent (0/1), supralevator 0 percent (0/2), and rectovaginal 33 percent (1/3; P = 1). The success rate for patients with no previous treatment was 38 percent (8/21) vs. 22 percent (4/18) in those whose fistulas had been previously treated ( P = 0.32). Eight patients underwent a second fibrin glue treatment and only one of them healed (12.5 percent). Median follow-up for successfully healed fistula was 26 months.

CONCLUSIONS

Fibrin glue treatment for complex anal fistulas has a low success rate and most recrudescences occurred within three months. However, given the low morbidity and relative simplicity of the procedure, fibrin glue should still be considered as a first-line treatment for patients with complex anal fistulas.

The addition of continuous infusion 5-FU to preoperative radiation therapy increases tumor response, leading to increased sphincter preservation in locally advanced rectal cancer

PURPOSE

To compare the outcome from preoperative chemoradiation (CXRT) and from radiation therapy (RT) in the treatment of rectal cancer in two large, single-institutional experiences.

PATIENTS AND METHODS

Between 1978 and 1995, 403 patients with localized, nonmetastatic, clinically staged T3 or T4 rectal cancer patients were treated with preoperative RT alone at two institutions. Patients at institution 1 (n = 207) were treated with pelvic CXRT exclusively, and patients at institution 2 were treated (except for 8 given CXRT) with pelvic RT alone (n = 196). In addition, a third group (n = 61) was treated with CXRT at institution 2 between 1998 and 2000 after a policy change. Both institutions delivered 45 Gy in five fractions as a standard dose, but institution 2 used 20 Gy in five fractions in selected cases (n = 26). At both institutions, concurrent chemotherapy consisted of a continuous infusion of 5-fluorouracil (5-FU) at a dosage of 1500 mg/m(2)/week. The end points were response, sphincter preservation (SP), relapse-free survival (RFS), pelvic disease control (PC), and overall survival (OS).

RESULTS

Median follow-up was 63 months for all living patients at institution 1 and in the primary group of institution 2. Multivariate analysis of the patients in these groups showed that the use of concurrent chemotherapy improved tumor response (T-stage downstaging, 62% vs. 42%, p = 0.001, and pathologic complete response, 23% vs. 5% p < 0.0001), but did not significantly improve LC, RFS, or OS. Follow-up for the secondary group at institution 2 was insufficient to allow the analysis of these endpoints. In the subset of patients receiving 45 Gy who had rectal tumors < or /=6 cm from the anal verge (institution 1: n = 132; institution 2 primary: n = 79; institution 2 secondary: n = 33), there was a significant improvement in SP with the use of concurrent chemotherapy (39% at institution 1 compared with 13% in the primary group at institution 2, p < 0.0001). A logistic regression analysis of clinical prognostic factors indicated that the use of concurrent chemotherapy independently influenced SP in these low tumors (p = 0.002). This finding was supported by a 36% SP rate in the secondary group at institution 2. Thus SP increased after the addition of chemotherapy at institution 2.

CONCLUSIONS

The use of concurrent 5-FU with preoperative radiation therapy for T3 and T4 rectal cancer independently increases tumor response and may contribute to increased SP in patients with low rectal cancer.

Prospective evaluation of anesthetic technique for anorectal surgery

PURPOSE

Deep intravenous sedation plus local anesthesia for anorectal surgery in the prone position is used frequently at our institution, but is not widely accepted because of concerns regarding airway management. The purpose of this study was to prospectively evaluate the safety and efficacy of this anesthetic technique for anorectal surgery.

METHODS

Data were collected prospectively on 413 consecutive patients (mean age, 47 years; mean weight, 80 kg) undergoing anorectal surgical procedures.

RESULTS

Of the 389 patients who underwent anorectal procedures in the prone position, 260 (67 percent) received intravenous sedation plus local anesthesia, 125 (32 percent) received regional anesthesia (spinal or epidural), and 4 (1 percent) received general endotracheal anesthesia. Of the 24 patients who underwent anorectal procedures in the lithotomy position, 13 (54 percent) received intravenous sedation plus local anesthesia, 2 (8 percent) received regional anesthesia, 2 (8 percent) received general endotracheal anesthesia, and 7 (29 percent) received mask inhalational anesthesia. Forty-two adverse events attributable to the anesthetic occurred in 18 patients: nausea and vomiting (n = 17), transient hypotension, bradycardia, or arrhythmia (n = 8), transient hypoxia or hypoventilation (n = 7), urinary retention (n = 6), and severe patient discomfort (n = 2). These complications occurred in 4 percent (10/273) of patients receiving intravenous sedation plus local anesthesia and in 6 percent (8/127) of patients receiving regional anesthesia. Two of 260 patients (0.8 percent) receiving intravenous sedation plus local anesthesia in the prone position were rolled supine before completing the surgical procedure. Recovery time before discharge for patients treated on an ambulatory basis was significantly shorter for those patients undergoing intravenous sedation plus local anesthesia (79 +/- 34 minutes, n = 174) than for patients undergoing regional anesthesia (161 +/- 63 minutes, n = 45; P < 0.001, t-test).

CONCLUSION

Intravenous sedation plus local anesthesia in the prone position is safe and effective for anorectal surgery and offers potential cost savings by decreasing recovery room time for outpatient procedures.

Wound complications of laparoscopic vs open colectomy

BACKGROUND

This study was conducted to determine if laparoscopic colon surgery has changed the incidence of wound complications after colon resection.

METHODS

Eighty-three patients were randomized to undergo either laparoscopic (LCR) or open colon resection (OCR) for cancer at our institution as part of a multicenter trial. Data were tabulated from review of the prospective database and physician records.

RESULTS

Thirty-seven patients were randomized to LCR and 46 to OCR. Seven patients in the LCR group were converted to OCR. LCR was performed using a limited midline incision for anastomosis and specimen extraction. Incision length was significantly greater (p <0.001) in the OCR group (19.4 +/- 5.6 cm) compared to the LCR extraction site (6.3 +/- 1.4 cm). Wound infections occurred in 13.5% of patients after LCR (2.7% trocar, 10.8% extraction sites) and in 10.9% of patients after OCR. Over a mean follow-up period of 30.1 +/- 17.8 months, incisional hernias developed in 24.3% of patients after LCR and 17.4% after OCR. In the LCR group, extraction sites accounted for 85.7% of all wound complications.

CONCLUSIONS

The extraction site for LCR is associated with a high incidence of complications, comparable to open colectomy. Strategies to alter operative technique should be considered to reduce the incidence of these complications.

Surgeon specialty is associated with outcome in rectal cancer treatment

PURPOSE

The aim of this study was to determine the effect of surgeon specialty on disease-free survival and local control in patients with adenocarcinoma of the rectum. Patients underwent curative treatment with neoadjuvant external beam radiotherapy and proctectomy by colorectal surgeons and noncolorectal surgeons.

METHODS

The records of 384 consecutive patients treated by colorectal surgeons (n = 251) and noncolorectal surgeons (n = 133) from 1977 to 1995 were reviewed independently by physicians in the Division of Radiation Oncology. Local recurrence was defined as pelvic recurrence occurring in the presence or absence of distant metastatic disease.

RESULTS

The study population comprised 213 males, mean age 64 (range, 19-97) years. Preoperative radiotherapy was delivered as 4,500 cGy in 25 fractions six to eight weeks before surgery (n = 293) or 2,000 cGy in 5 fractions immediately before surgery (n = 91). Concurrent preoperative chemotherapy was given to 14 patients, postoperative chemotherapy to 55. Overall actuarial disease-free survival and local control rates were 74 and 90 percent, respectively, at five years. Actuarial disease-free survival and local control rates at five years were 77 and 93 percent for colorectal surgeons vs. 68 and 84 percent for noncolorectal surgeons (P < or = 0.005 for both, Tarone-Ware). Multivariate analysis revealed that pathologic stage and background of the surgeon were the only independent predictors of disease-free survival (both P < or = 0.006, Cox proportional hazards) and that pathologic stage, background of the surgeon, and proximal location of the tumor were independent predictors of local control (all P < or = 0.02, Cox proportional hazards). Radiation dose and use of chemotherapy were not significant factors. Sphincter preservation was more common by colorectal surgeons (131/251, 52 percent) than noncolorectal surgeons (40/133, 30 percent; P = 0.00004, Fisher's exact test, two-tailed).

CONCLUSION

Good outcome for patients with adenocarcinoma of the rectum who undergo neoadjuvant external beam radiotherapy and proctectomy is associated with subspecialty training in colon and rectal surgery.

Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon

BACKGROUND

There is wide variability in reported locoregional recurrence rates after curative resection of adenocarcinoma of the intraperitoneal colon, and there is no universally accepted surgical technique regarding length of the resected specimen or extent of lymphadenectomy. The aim of this study was to determine the disease-free survival, locoregional failure, and perioperative morbidity of patients undergoing curative resection of colon adenocarcinoma.

STUDY DESIGN

The records of 316 consecutive patients undergoing curative resection for primary adenocarcinoma of the intraperitoneal colon between 1990 and 1995 were reviewed. Locoregional recurrence was defined as disease at the anastomosis or in the adjacent mesentery, peritoneum, retroperitoneum, or carcinomatosis. The product-limit method (Kaplan-Meier) was used to analyze survival and tumor recurrence.

RESULTS

The study population comprised 167 men and 149 women, mean age 70+/-12 years (range 22 to 95 years). Median followup was 63+/-25 months. Five-year disease-free survival was 84% overall. Disease-free survival paralleled tumor stage: stage I, 99% (n = 73); stage II, 87% (n = 151); stage III, 72% (n = 92). The predominant pattern of tumor recurrence was distant failure only. Overall locoregional recurrence (locoregional and locoregional plus distant) at 5 years was 4%. Locoregional recurrence paralleled tumor stage: stage I, 0%; stage II, 2%; stage III, 10%. Of the 12 patients who suffered locoregional recurrence, 9 (75%) had T4 primary tumors, N2 nodal disease, or both. Major and minor complications occurred in 93 patients (29%) including: anastomotic leak or intraabdominal abscess (n = 4, 1%); hemorrhage (n = 8, 3%); cardiac complications (n= 17, 5%); pulmonary embolism (n=4, 10%); death (n=2, 1%). Multivariate analysis (Cox proportional hazards) revealed that the only independent predictor of disease-free survival and locoregional control was tumor stage.

CONCLUSION

Longterm survival and locoregional control can be achieved for patients with colon cancer, with low morbidity. In the absence of adjacent organ invasion and N2 nodal disease, locoregional recurrence should be a rare event. Just as for rectal cancer, the technical aspects of colectomy for colon cancer deserve renewed attention.

Early experience with stapled hemorrhoidectomy in the United States

INTRODUCTION

We report the early results of patients treated with stapled hemorrhoidectomy, which has recently been introduced into the United States.

METHODS

Sixty-eight patients with symptomatic hemorrhoids were treated at two institutions with the Proximate HCS Hemorrhoidal Circular Stapler supplied by Ethicon Endo-Surgery. Patients were prospectively evaluated for functional recovery and postoperative pain on a 1 to 10 scale.

RESULTS

There were 45 (66 percent) males and 23 (34 percent) females with a mean age of 56 years and median duration of symptoms of 5 years. The mean operative time was 22.2 minutes. The operation was performed with spinal (50 percent), local (40 percent), or general (10 percent) anesthesia and as an outpatient (56 percent) or overnight admission (44 percent). Ninety-three percent of patients remained asymptomatic with a mean follow-up of 34 weeks, whereas the remaining 7 percent required either surgical excision or rubber band ligation for persistent symptoms. There was no mortality, new incontinence, fecal impaction, or persistent pain. The total morbidity was 19 percent, with urinary retention as the most common complication (12 percent). The mean pain score decreased from 3.6 on postoperative Day 1 to 1.4 at postoperative Day 7. Ninety-nine percent of patients made a complete functional recovery by postoperative Day 7.

CONCLUSIONS

Stapled hemorrhoidectomy is safe, effective, and can be performed as an outpatient procedure with local or regional anesthesia. There seems to be minimal postoperative pain and early recovery, although a benefit over traditional hemorrhoidectomy needs to be proven in a randomized trial.

Neoadjuvant external beam radiation and proctectomy for adenocarcinoma of the rectum

PURPOSE

The aim of this study was to determine the survival rate, local failure, and perioperative morbidity in patients with adenocarcinoma of the rectum undergoing curative proctectomy who were felt to have transmural disease on preoperative assessment. Eighty-nine percent of these patients were treated with preoperative external beam radiotherapy.

METHODS

The records of 191 consecutive patients undergoing abdominal surgical procedures for primary treatment of rectal cancer were reviewed. The product-limit method (Kaplan-Meier) was used to analyze survival rate and tumor recurrence.

RESULTS

One patient was excluded from survival analysis because of incomplete record of tumor stage. The study population comprised 109 males and 81 females, median age 64 (range, 33-91) years. Curative resection was performed in 152 of these 190 patients (80 percent), including low anterior resection with coloproctostomy or coloanal anastomosis (n = 103), abdominoperineal resection (n = 44), Hartmann's procedure (n = 4), and pelvic exenteration (n = 1). Mean follow-up of patients undergoing curative resection was 96 +/- 48 months. Palliative procedures were performed in 38 of 190 patients (20 percent). Perioperative mortality was 0.5 percent (1/190). Complications occurred in 64 patients (34 percent). The anastomotic leak rate was 4 percent (5/128). Disease-free five-year survival rate by pathologic stage was as follows: Stage I, 90 percent; Stage II, 85 percent; Stage III, 54 percent; Stage IV, 0 percent; and no residual tumor, 90 percent. Of the 152 patients treated with curative resection, disease-free survival rate was 80 percent at five years. Preoperative external beam radiation was administered to 135 of these 152 patients (89 percent). Tumor recurred in 32 of 152 patients (21 percent) treated with curative resection. The predominant pattern of recurrence was distant failure only. Kaplan-Meier overall local recurrence (local and local plus distant) at five years was 6.6 percent. The local recurrence rate paralleled tumor stage: Stage I, 0 percent; Stage II, 6 percent; Stage III, 20 percent; and no residual tumor, 0 percent.

CONCLUSION

Preoperative external beam radiotherapy and attention to mesorectal dissection can achieve low local recurrence and excellent long-term survival rate in patients with adenocarcinoma of the rectum. Moreover, these goals can be obtained with low morbidity and mortality.

Radiation therapy for epidermoid carcinoma of the anal canal, clinical and treatment factors associated with outcome

BACKGROUND AND PURPOSE

In recent years, treatment with combined chemotherapy and radiation has become the standard of care for epidermoid carcinoma of the anus. However, optimal radiotherapy techniques and doses are not well established.

MATERIALS AND METHODS

During the period 1975-1997, 106 patients with epidermoid carcinoma of the anal canal underwent radiation therapy. Treatment policies evolved from radiation therapy alone or with surgery, to combined chemotherapy and radiation followed by surgery, to combined chemotherapy and radiation.

RESULTS

Overall 74% of patients were NED (no evidence of disease) at last follow-up. The most important clinical correlate with ultimate freedom from disease (includes the contribution of salvage surgery) was extent of disease. The 5-year ultimate freedom from disease was 87+/-5% for T1/T2N0, 78+/-10% for T3N0 (15% salvaged by surgery), and 43+/-10% for either T4N0 or any N+ lesions (P<0.001, Tarone-Ware). There was no difference between planned vs. expectant surgery (5-year ultimate NED: 67+/-11% planned surgery vs. 73+/-5% expectant surgery). The most important correlate with late toxicity was a history of major pelvic surgery (surgical vs. non-surgical group: P=0.013, Fisher's exact test, two-tailed summation). Thirty-three additional malignancies have been seen in 26 patients. The most common additional malignancies were gynecologic (nine cases), head and neck (six cases), and lung cancer (five cases).

CONCLUSIONS

For T1/T2N0 disease, moderate doses of radiation combined with chemotherapy provided adequate treatment. T4N0 and N+ lesions are the most appropriate candidates for investigational protocols evaluating dose intensification. T3N0 tumors may also be appropriate for investigation; however, dose intensification may ultimately prove counterproductive if the cure rate is not improved and salvage surgery is rendered more difficult. The volume of irradiated small bowel should be minimized for patients who have a past history of major pelvic surgery or who (because of locally advanced tumors) may need salvage surgery in the future. Because of the occurrence of additional malignancy, patients with anal cancer should receive general oncologic screening in long-term follow-up.

Treatment of rectal adenocarcinoma with endocavitary and external beam radiotherapy: results for 199 patients with localized tumors

PURPOSE

Endocavitary radiation (RT) provides a conservative alternative to proctectomy. Although most suitable for small, mobile lesions, patients with less favorable tumors are often referred if they are poor surgical candidates. Knowing the extent to which radiation can control such tumors can be an important factor in making clinical decisions.

METHODS AND MATERIALS

One hundred ninety-nine patients, who received endocavitary RT with or without external beam RT (EBRT) during 1981 through 1995, were followed for disease status for a median of 70 months, including deaths from intercurrent causes. In the early years of the study, 21 patients were treated with endocavitary RT alone, the remainder of the patients received pelvic EBRT (usually 45 Gy in 25 fractions) 5-7 weeks before endocavitary RT.

RESULTS

Overall, 141 patients (71%) had local control with RT alone. Salvage surgery rendered an additional 20 patients disease free, for an ultimate local control rate of 81%. On multivariate analysis for local control (excluding surgical salvage), the most significant factors were mobility to palpation, use of EBRT, and whether pretreatment debulking of all macroscopic disease had been done (generally a piecemeal, nontransmural procedure). Of 77 cases staged by transrectal ultrasonography, the local control rate with RT alone was 100% for uT1 lesions, 85% (90% with no evidence of disease after salvage) for freely mobile uT2 lesions, and 56% (67% with no evidence of disease after salvage) for uT3 lesions and uT2 lesions that were not freely mobile.

CONCLUSIONS

Patients with small mobile tumors that are either uT1 or have only a scar after debulking achieve excellent local control with endocavitary RT. About 15% of mobile uT2 tumors fail RT; therefore, careful follow-up is critical. Small uT3 tumors are appropriate for this treatment only if substantial contraindications to proctectomy are present.

A phase I/II trial of three-dimensionally planned concurrent boost radiotherapy and protracted venous infusion of 5-FU chemotherapy for locally advanced rectal carcinoma

BACKGROUND

Improving the response to preoperative therapy may increase the likelihood of successful resection of locally advanced rectal cancers. Historically, the pathologic complete response (pCR) rate has been < approximately 10% with preoperative radiation therapy alone and < approximately 20% with concurrent chemotherapy and radiation therapy.

METHODS AND MATERIALS

Thirty-seven patients were enrolled on a prospective Phase I/II protocol conducted jointly at Washington University, St. Louis and the Catholic University of the Sacred Heart, Rome evaluating a three-dimensionally (3D) planned boost as part of the preoperative treatment of patients with unresectable or recurrent rectal cancer. Preoperative treatment consisted of 4500 cGy in 25 fractions over 5 weeks to the pelvis, with a 3D planned 90 cGy per fraction boost delivered once or twice a week concurrently (no time delay) with the pelvic radiation. Thus, on days when the boost was treated, the tumor received a dose of 270 cGy in one fraction while the remainder of the pelvis received 180 cGy. When indicated, nonaxial beams were used for the boost. The boost treatment was twice a week (total boost dose 900 cGy) if small bowel could be excluded from the boost volume, otherwise the boost was delivered once a week (total boost dose 450 cGy). Patients also received continuous infusion of 5-fluorouracil (1500 mg/m(2)-week) concurrently with the radiation as well as postoperative 5-FU/leucovorin.

RESULTS

All 37 patients completed preoperative radiotherapy as planned within 32--39 elapsed days. Twenty-seven underwent proctectomy; reasons for unresectability included persistent locally advanced disease (6 cases) and progressive distant metastatic disease with stable or smaller local disease (4 cases). Actuarial 3-year survival was 82% for the group as a whole. Among resected cases the 3-year local control and freedom from disease relapse were 86% and 69%, respectively.Twenty-four of the lesions (65%) achieved an objective clinical response by size criteria, including 9 (24%) with pCR at the primary site (documented T0 at surgery). The most important factor for pCR was tumor volume: small lesions with planning target volume (PTV) < 200 cc showed a 50% pCR rate (p = 0.02). There were no treatment associated fatalities. Nine of the 37 patients (24%) experienced Grade 3 or 4 toxicities (usually proctitis) during preoperative treatment. There were an additional 7 perioperative and 2 late toxicities. The most important factors for small bowel toxicity (acute or late) were small bowel volume (> or = 150 cc at doses exceeding 4000 cGy) and large tumor (PTV > or = 800 cc). For rectal toxicity the threshold is PTV > or = 500 cc.

CONCLUSION

3D planned boost therapy is feasible. In addition to permitting the use of nonaxial beams for improved dose distributions, 3D planning provides tumor and normal tissue dose-volume information that is important in interpreting outcome. Every effort should be made to limit the treated small bowel to less than 150 cc. Tumor size is the most important predictor of response, with small lesions of PTV < 200 cc most likely to develop complete responses.

Pretreatment clinical findings predict outcome for patients receiving preoperative radiation for rectal cancer

BACKGROUND

As a sole modality, preoperative radiation for rectal carcinoma achieves a local control comparable to that of postoperative radiation plus chemotherapy. Although the addition of chemotherapy to preoperative treatment improves the pathologic complete response rate, there is also a substantial increase in acute and perioperative morbidity. Identification of subsets of patients who are at low or high risk for recurrence can help to optimize treatment.

METHODS

During the period 1977-95, 384 patients received preoperative radiation therapy for localized adenocarcinoma of the rectum. Ages ranged from 19 to 97 years (mean 64.4), and there were 171 females. Preoperative treatment consisted of conventionally fractionated radiation to 3600-5040 cGy (median 4500 cGy) 6-8 weeks before surgery in 293 cases or low doses of <3000 cGy (median 2000 cGy) immediately before surgery in 91 cases. Concurrent preoperative chemotherapy was given to only 14 cases in this study period. Postoperative chemotherapy was delivered to 55 cases.

RESULTS

Overall 93 patients have experienced recurrence (including 36 local failures). Local failures were scored if they occurred at any time, not just as first site of failure. For the group as a whole, the actuarial (Kaplan-Meier) freedom from relapse (FFR) and local control (LC) were 74% and 90% respectively at 5 years. Univariate analysis of clinical characteristics demonstrated a significant (p < 0.05) adverse effect on both LC and FFR for the following four clinical factors: (1) location <5 cm from the verge, (2) circumferential lesion, (3) near obstruction, (4) tethered or fixed tumor. Size, grade, age, gender, ultrasound stage, CEA, radiation dose, and the use of chemotherapy were not associated with outcome. Background of the surgeon was significantly associated with outcome, colorectal specialists achieving better results than nonspecialist surgeons. We assigned a clinical score of 0 to 2 on the basis of how many of the above four adverse clinical factors were present: 0 for none, 1 for one or two, 2 for three or four. This sorted outcome highly significantly (p < or = 0.002, Tarone Ware), with 5-year LC/FFR of 98%/85% (score 0), 90%/72% (score 1), and 74%/58% (score 2). The scoring system sorts the data for both subgroups of surgeons; however, there are substantial differences in LC on the basis of the surgeon's experience. For colorectal specialists (251 cases), the 5-year LC is 100%, 94%, and 78% for scores of 0, 1, and 2, respectively (p = 0.004). For the more mixed group of nonspecialist surgeons (133 cases), LC is 98%, 80%, and 65% for scores of 0, 1, and 2 (p = 0.008). In multivariate analysis, the clinical score and surgeon's background retained independent predictive value, even when pathologic stage was included.

CONCLUSIONS

For many patients with rectal cancer, adjuvant treatment can be administered in a well-tolerated sequential fashion-moderate doses of preoperative radiation followed by surgery followed by postoperative chemotherapy to address the risk of occult metastatic disease. A clinical scoring system has been presented here that would suggest that the local control is excellent for lesions with a score of 0 or (if the surgeon is experienced) 1, and therefore sequential treatment could be considered. Cases with a clinical score of 2 should be strongly considered for protocols evaluating more aggressive preoperative treatment, such as combined modality preoperative treatment.

Manometric squeeze pressure difference parallels functional outcome after overlapping sphincter reconstruction

PURPOSE

This study was designed to evaluate the effectiveness of overlapping anal sphincter reconstruction and to determine the manometric parameters that correlate with a successful functional outcome.

METHODS

A retrospective review of patients who had undergone overlapping sphincter reconstruction for anal incontinence from 1988 to 1999 was undertaken. Only patients with preoperative and six-months-postoperative anal manometry were included in this study. Standard statistical tests were used to compare pre- and postoperative findings.

RESULTS

A total of 52 overlapping sphincter reconstructions were performed on 49 patients (46 females). The mean age was 44 (+/- standard error, 15.8; range, 20-81) years, with follow-up at six months. Forty-two patients had a history of complicated vaginal delivery (episiotomies, tears, forceps delivery); 36 patients had a history of anal or perineal surgery; and two patients had perianal Crohn's disease. Nine patients (17 percent) had undergone prior sphincter repair. Incontinence grade improved in 37 patients (71 percent), and complete continence returned in 21 patients (40 percent). The presence of a rectovaginal fistula, postoperative complications, previous sphincter repair, and increase in pudendal nerve terminal motor latency did not affect functional outcome (P = not significant). Patients older than 50 years had a better functional outcome than their younger counterparts after sphincter repair (P = 0.02). Although mean maximal squeeze pressure and mean anal sphincter length increased significantly after sphincter reconstruction (P = 0.0006 and 0.004, respectively), only squeeze pressure difference correlated with functional outcome (r = 0.37; P = 0.007).

CONCLUSIONS

Overlapping sphincter reconstruction improved anal function in the majority of patients. The most important factor in the return to normal sphincter function is an increase in squeeze pressure.

Neoadjuvant therapy for adenocarcinoma of the rectum: tumor response and acute toxicity

PURPOSE

This study was designed to evaluate the down-staging effect and acute toxicity of preoperative radiation and chemoradiation for primary adenocarcinoma of the rectum.

METHODS

The results of pretreatment staging with transrectal ultrasound and computed tomography were compared with final histologic stage in 260 consecutive patients who underwent neoadjuvant therapy and proctectomy for primary adenocarcinoma of the rectum. Patients underwent short-course radiation (2,000 cGy in five fractions), long-course radiation (4,500 cGy in 25 fractions), or chemoradiation (4,500 cGy in 25 fractions with concurrent chemotherapy).

RESULTS

Down-staging of one or more T stages occurred in 116 of 260 (45 percent) patients overall (short-course radiation 34/82 (42 percent), long-course radiation 55/122 (45 percent), chemoradiation 27/56 (48 percent), P = not significant). Down-staging of one or more N stages occurred in 85 of 178 (48 percent) patients overall (short-course radiation 12/45 (27 percent), long-course radiation 49/86 (57 percent), chemoradiation 24/47 (51 percent), P = 0.003). Complete pathologic response was observed in 16 of 260 (6 percent) patients overall (short-course radiation 4/82 (5 percent), long-course radiation 5/122 (4 percent), chemoradiation 7/56 (13 percent), P = 0.08). Resection with negative margins (distal, proximal, and radial) was achieved in 211 of 227 patients (93 percent) in whom complete radial margin data were available. Permanent stomas were created in 35 percent of patients; temporary stomas were created in 15 percent. Thirty-three Grade 3 or 4 toxicities occurred in 22 of 260 (8 percent) patients overall during neoadjuvant therapy. Toxicity was more frequent in patients receiving chemoradiation (14/56; 25 percent) and long-course radiation (8/122; 7 percent) than in those receiving short-course radiation (0/82; 0 percent), P < 0.0001. Perioperative complications occurred in 93 patients overall (36 percent). The postoperative mortality rate was 0.4 percent (1/260). There was no significant difference in the complication rate between patients treated with short-course radiation (26/82; 32 percent), long-course radiation (46/122; 36 percent), and chemoradiation (21/56; 38 percent).

CONCLUSION

Neoadjuvant therapy for adenocarcinoma of the rectum is well tolerated and can produce substantial down-staging and a high curative resection rate. Chemoradiation can achieve high complete pathologic response rates, although toxicity during neoadjuvant therapy is greater than for radiation alone. Short-course radiation can achieve down-staging of both T stage and N stage.

Outcome of patients with rectal adenocarcinoma and localized pelvic non-nodal metastatic foci

PURPOSE

The aim of this study was to evaluate the outcome of patients with primary rectal adenocarcinoma and soft tissue metastatic foci restricted to the pelvis and to determine whether this entity, which is considered N1 disease in the American Joint Committee on Cancer staging system, behaves like completely replaced nodal disease or the first sign of M1 disease. The clinical course for patients with this finding is not well-described in the literature.

METHODS

The authors retrospectively reviewed the medical records of 395 patients with rectal adenocarcinoma who received radiation treatment. Eighteen patients had pelvic soft tissue metastatic foci. Exclusions from this study included 1) cases without metastatic pelvic foci; 2) cases of recurrent cancer; 3) cases with known distant metastatic disease as defined by American Joint Committee on Cancer criteria; and 4) cases with extrapelvic metastatic foci. All patients received adjuvant radiotherapy. Thirteen cases received preoperative radiotherapy. Four cases received postoperative radiotherapy. One case received both preoperative and postoperative radiotherapy. Eight cases received chemotherapy.

RESULTS

All eighteen patients had T3 or T4 lesions. Thirteen patients had lymph nodes that contained metastatic disease and would therefore have been scored N1 or N2 even without the pelvic tumor implants. Sixteen of 18 (89 percent) patients died of disease after a survival time of 12 to 37 (mean, 25) months. Only 1 of 18 (6 percent) patients was disease free at five years. The other remaining survivor was undergoing palliative therapy for metastatic disease to the lung. This is significantly worse than our institution's experience with T3,4N+ disease after preoperative radiation (5-year survival, 11 vs. 56 percent; P = 0.0002, Generalized Wilcoxon of Breslow). There was a high incidence of local (9/18) and distant (14/18) failure. No other factor, including radiation dose, margin status, chemotherapy, T stage, and number of involved nodes or soft tissue implants, correlated independently with outcome.

CONCLUSIONS

Pelvic metastatic foci confer a significantly worse prognosis than other T3,4N+ disease. Such cases should be excluded from prospective trials for localized disease. Although this entity probably represents M1 disease for most patients, survival can be long, and aggressive locoregional and systemic treatment is warranted.

Usefulness of FDG-PET scan in the assessment of suspected metastatic or recurrent adenocarcinoma of the colon and rectum

PURPOSE

The purpose of this study was to evaluate the clinical efficacy of positron emission tomography with 2-[18F] fluoro-2-deoxy-D-glucose compared with computed tomography plus other conventional diagnostic studies in patients suspected of having metastatic or recurrent colorectal adenocarcinoma.

METHODS

The records of 105 patients who underwent 101 computed tomography and 109 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography scans for suspected metastatic or recurrent colorectal adenocarcinoma were reviewed. Clinical correlation was confirmed at time of operation, histopathologically, or by clinical course.

RESULTS

The overall sensitivity and specificity of 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography in detection of clinically relevant tumor were higher (87 and 68 percent) than for computed tomography plus other conventional diagnostic studies (66 and 59 percent). The sensitivity of 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography in detecting mucinous cancer was lower (58 percent; n = 16) than for nonmucinous cancer (92 percent; n = 93). The sensitivity of 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography in detecting locoregional recurrence (n = 70) was higher than for computed tomography plus colonoscopy (90 vs. 71 percent, respectively). The sensitivity of 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography in detecting hepatic metastasis (n = 101) was higher than for computed tomography (89 vs. 71 percent). The sensitivity of 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography in detecting extrahepatic metastases exclusive of locoregional recurrence (n = 101) was higher than for computed tomography plus other conventional diagnostic studies (94 vs. 67 percent). 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography altered clinical management in a beneficial manner in 26 percent of cases (26/101) when compared with evaluation by computed tomography plus other conventional diagnostic studies.

CONCLUSION

2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography is more sensitive than computed tomography for the detection of metastatic or recurrent colorectal cancer and may improve clinical management in one-quarter of cases. However, 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography is not as sensitive in detecting mucinous adenocarcinoma, possibly because of the relative hypocellularity of these tumors.

Use of endoanal ultrasound in patients with rectovaginal fistulas

PURPOSE

The purpose of our study was to define the role of endoanal ultrasound in the evaluation and management of patients with rectovaginal fistula.

METHODS

A retrospective review was performed of all patients with rectovaginal fistula who were evaluated by endoanal ultrasound at Barnes-Jewish Hospital at Washington University from 1992 to 1997.

RESULTS

Twenty-five females underwent endoanal ultrasound before rectovaginal fistula repair. Mean age was 34 years. Rectovaginal fistulas were caused by obstetric trauma (19 patients; 76 percent), cryptoglandular disease (5 patients; 20 percent), and Crohn's disease (1 patient; 4 percent). Previous rectovaginal fistula repair had been performed in ten patients (40 percent). A history of anal incontinence was present in ten patients (40 percent). Rectovaginal fistula location was above (15 patients), at (7 patients), or below (3 patients) the dentate line. Rectovaginal fistula size was <5 mm (19 patients; 76 percent) or >5 mm (6 patients; 24 percent). Anal manometry revealed decreased sphincter pressures (resting or squeeze) in 12 patients (48 percent). Pudendal nerve latency was abnormal in three patients (9 percent). Endoanal ultrasound identified the rectovaginal fistula in 7 patients (28 percent) and an anterior sphincter defect in 23 patients (92 percent). At surgery sphincter injuries were identified in 23 patients (92 percent). Treatment was either sliding flap repair with anal sphincter reconstruction (22 patients; 88 percent) or sliding flap repair alone (3 patients; 12 percent). Repair of the rectovaginal fistula was successful in 23 patients (92 percent). Complications occurred in 11 patients (44 percent): two recurrent rectovaginal fistulas, five infections, two skin separations, one ectropion, and one hematoma. The two patients with recurrent rectovaginal fistula had prior repairs, and both were subsequently repaired successfully. Of the 11 patients with preoperative anal incontinence, 6 patients (54 percent) were continent and 2 (18 percent) improved after surgery. Cause, size, location, and previous repair of fistula had no effect on final outcome.

CONCLUSIONS

Noncontrast endoanal ultrasound was not useful in imaging rectovaginal fistulas and cannot be recommended as a diagnostic or screening tool for the identification of a rectovaginal fistula. However, we recommend that endoanal ultrasound be performed preoperatively in all patients with known rectovaginal fistulas to identify and map occult sphincter defects. Concomitant anal sphincter reconstruction should be considered strongly in patients with rectovaginal fistula and an endoanal ultrasound-documented sphincter defect.

Laparoscopic vs. 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 (24 vs. 8 percent; P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7 vs. 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.

Selection criteria for treatment of rectal cancer with combined external and endocavitary radiation

PURPOSE

The aim of this study was to identify factors predictive of recurrence of rectal tumors treated with combined external and endocavitary radiation.

METHODS

Seventy-two patients with rectal cancer were evaluated clinically and with transrectal ultrasound before combined external and endocavitary radiation. Ideal lesions were moderately differentiated, mobile, not ulcerated, <3 cm in diameter, and <12 cm from the anal verge. External radiation (4,500 cGy) was given during five weeks followed by endocavitary radiation (3,000 cGy x 2). Median follow-up was 31 (range, 7-93) months.

RESULTS

Pretreatment transrectal ultrasound stages were uT1 (6 patients), uT2 (27 patients), and uT3 (39 patients). Clinical evaluation identified 26 ideal and 46 nonideal tumors. Overall recurrence was 36 percent; mean time to recurrence was 12 months. Ideal lesions recurred less than nonideal (15 vs. 48 percent; P = 0.01). Mobile lesions recurred less than tethered lesions (26 vs. 52 percent; P = 0.048). Transrectal ultrasound stage was predictive of recurrence (0 percent uT1, 22 percent uT2, and 51 percent uT3; P = 0.015). Surgery was possible in 14 of 17 patients with pelvic recurrence only; 11 patients (65 percent) had curative surgery. Distant metastases occurred in nine patients; all had pelvic recurrences, and six died of disease.

CONCLUSION

Patients with uT3 or nonideal rectal cancers should not be offered combined external and endocavitary radiation for cure. Transrectal ultrasound stage is the only independent predictor of recurrence.

Confirmation that chromosome 18q allelic loss in colon cancer is a prognostic indicator

PURPOSE

Recent studies suggest that allelic loss of sequences from the long arm of chromosome 18 may be a useful prognostic indicator in colorectal cancer. The aim of the present study was to confirm whether 18q loss of heterozygosity (LOH) is of prognostic value in patients with colon cancer.

METHODS

Genomic DNA was prepared from archival tumor and corresponding normal tissue specimens from 151 patients who had undergone potentially curative surgery for adenocarcinoma of the colon. Polymerase chain reaction (PCR) was used to assess allelic loss of five chromosome 18q microsatellite markers in the tumors. The relationship between allelic loss and disease-free and disease-specific survival was investigated.

RESULTS

LOH was detected in 67 of 126 tumors. Chromosome 18q allelic loss was a negative prognostic indicator of both disease-free (relative risk [RR], 1.65; P = .01) and disease-specific survival (RR, 2.0; P = .003). 18q loss was also associated with significantly reduced disease-free and disease-specific survival in patients with stage II (P = .05 and P = .0156) and III (P = .038 and P = .032) disease.

CONCLUSION

Chromosome 18q allelic loss is a prognostic marker in colorectal cancers. Chromosome 18 LOH studies may be useful in identifying patients with stage II disease who are at high risk for recurrence, and as such might benefit from adjuvant chemotherapy.

Detection of recurrent and metastatic colorectal cancer: comparison of positron emission tomography and computed tomography

BACKGROUND

This study evaluates the clinical value of positron emission tomography (PET) with 2-[F-18] fluoro-2-deoxy-D-glucose (FDG) as compared to computed tomography (CT) in patients with suspected recurrent or metastatic colorectal cancer (CRC).

METHODS

A retrospective review of the records of 58 patients who had FDG-PET for evaluation of recurrent or advanced primary CRC was performed. FDG-PET results were compared with those of CT and correlated with operative and histopathologic findings, or with clinical course and autopsy reports.

RESULTS

Recurrent or advanced primary CRC was diagnosed in 40 and 11 patients, respectively. The sensitivity and specificity of FDG-PET were 91% and 100% for detecting local pelvic recurrence, and 95% and 100% for hepatic metastases. These values were superior to CT, which had sensitivity and specificity of 52% and 80% for detecting pelvic recurrence, and 74% and 85% for hepatic metastases. FDG-PET correctly identified pelvic recurrence in 19 of 21 patients; CT was negative in 6 of these patients and equivocal in 4. FDG-PET was superior to CT in detecting multiple hepatic lesions and influenced clinical management in 10 of 23 (43%) patients.

CONCLUSION

FDG-PET is more sensitive than CT in the clinical assessment of patients with recurrent or metastatic CRC, and provides an accurate means of selecting appropriate treatment for these patients.

Laparoscopic-assisted ileocolic resections in patients with Crohn's disease: are abscesses, phlegmons, or recurrent disease contraindications?

BACKGROUND

Because of the inflammatory nature of Crohn's disease, ileocolic resections are often difficult to perform, especially if an abscess, phlegmon, or recurrent disease at a previous ileocolic anastomosis is present. Our goal was to determine whether the above factors are contraindications to a successful laparoscopic-assisted ileocolic resection.

METHODS

Between 1992 and 1996, 46 laparoscopic-assisted ileocolic resections were attempted. Fourteen patients had an abscess or phlegmon treated with bowel rest before operation (group I), 10 patients had recurrent Crohn's disease at the previous ileocolic anastomosis (group II), and 22 patients had no previous operation and no phlegmon or abscess associated with their disease (group III). These groups were compared with each other and with 70 consecutive open ileocolic resections for Crohn's disease during the same time period (group IV).

RESULTS

Operative blood loss and time were greater in group IV than in groups I, II, and III (245 versus 151, 131, and 195 ml, respectively, and 202 versus 152, 144, and 139 minutes, respectively). Conversion to open procedure occurred in 5 patients (group I, 1 [7%]; group II, 2 [20%]; group III, 2 [9%]). Morbidity was highest in group IV (21% versus 0%, 10%, and 10%, respectively). Only one patient died (group IV, 1%). Length of hospital stay was longest in group IV (7.9 versus 4.8, 3.9, and 4.5 days, respectively).

CONCLUSIONS

The laparoscopic-assisted approach to Crohn's disease is feasible and safe with good outcomes. Co-morbid preoperative findings such as abscess, phlegmon, or recurrent disease at the previous ileocolic anastomosis are not contraindications to a successful laparoscopic-assisted ileocolic resection in select patients.

Prognostic value of chromosome 1p allelic loss in colon cancer

BACKGROUND & AIMS

Current evidence suggests that there may be a tumor-suppressor gene on chromosome 1p associated with colorectal cancer. The aim of the present study was to determine whether allelic loss on chromosome 1p is of prognostic value in colorectal cancer.

METHODS

Polymerase chain reaction was used to assess allelic loss of five chromosome 1p microsatellite markers in tumor specimens. Genomic DNA was prepared from archival tumor and corresponding normal tissue specimens from 116 patients who had undergone curative treatment for adenocarcinoma of the colon. Allelic loss was correlated with disease-free interval and survival.

RESULTS

Deletion of 1p sequence was detected in 22 of 82 tumors. Deletions of the microsatellite markers D1S228 (1p36) and HY-TM1 (1p32) were significantly associated with poor survival (P < 0.05): relative risk, 4.1; 95% confidence interval, 1.25-9.23 for D1S228; and relative risk, 6.6; 95% confidence interval, 1.4-19 for HY-TM1. Loss of heterozygosity at D1S228 was also associated with shorter disease-free interval: relative risk, 4.5; 95% confidence interval, 1.3-11.

CONCLUSIONS

Allelic loss in the 1p36 and 1p32 regions of chromosome 1 appears to be an independent predictor of poor prognosis in patients with adenocarcinoma of the colon.

Early experience with laparoscopic abdominoperineal resection

BACKGROUND

Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center.

METHODS

A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient).

RESULTS

The procedure was converted to open procedure in four patients (19%). The mean (+/-SEM) operative time and blood loss for completed and converted LAPR were 239 +/- 11 min and 424 +/- 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% +/- 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1-44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates.

CONCLUSION

Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients.