Inadvertent perforation during rectal cancer resection in Norway

Modern challenges in colorectal cancer

Colorectal cancer is a major problem worldwide and in the United Kingdom it is responsible for some 20,000 deaths per annum. Mortality from the disease is gradually decreasing in developed countries but, in the United Kingdom at least, its incidence is on the increase. In this article the major current challenges in colorectal cancer will be dealt with under the following headings: aetiology and prevention, early detection, diagnosis, surgery, adjuvant therapy and management of advanced disease.

Rectal cancer in the young patient

PURPOSE

The purpose of this national study was to evaluate the results of treatment for young rectal cancer patients.

METHODS

This prospective study from the Norwegian Rectal Cancer Project includes all 2,283 patients younger than aged 70 years with adenocarcinoma of the rectum from November 1993 to December 1999. Patients younger than aged 40 years (n = 45), 40 to 44 years (n = 87), 45 to 49 years (n = 153), and 50 to 69 years (n = 1998) were compared for patient and tumor characteristics and five-year overall survival. Patients treated for cure (n = 1,354) were evaluated for local recurrence, distant metastasis, and disease-free survival.

RESULTS

Patients younger than aged 40 years had significantly higher frequencies of poorly differentiated tumors (27 vs. 12-16 percent; P = 0.014), N2-stage (37 vs. 13-18 percent; P = 0.001), and distant metastases (38 vs. 19-24 percent; P = 0.019) compared with older patients. Among those treated for cure, 56 percent of the patients younger than aged 40 years developed distant metastases compared with 20 to 26 percent of the older patients (P = 0.003). Overall five-year survival was 54 percent for patients younger than aged 40 years compared with 71 to 88 percent for the older patients (P = 0.029). Age younger than 40 years was a significant independent prognostic factor and increased the risk for metastasis and death.

CONCLUSIONS

Patients younger than aged 40 years had a more advanced stage at the time of diagnosis and poor prognosis compared with older patients. Young patients treated for cure more often developed distant metastases and had inferior survival.

Can the results of anorectal (abdominoperineal) resection be improved: are circumferential resection margins too often positive?

Carefully executed surgery for rectal cancer has reduced the incidence of local recurrence after restorative resection. Three recent large prospective series have confirmed the perception of a higher positive circumferential resection margin (CRM) rate after abdominoperineal resection. Tumour spread is different for low tumours and the surgical technique of abdominoperineal resection, perhaps better known as anorectal excision, may vary between surgeons. There is a need to redefine the place of anorectal excision and the contribution that can be made by pre-operative chemoradiation and/or extended surgery to reduce local recurrence and increase survival. Defined surgery, validated by histopathological assessment, as applied to TME surgery, would determine whether the perceived higher rates are due to the differences in routes of tumour spread or to surgically related variables. Unnecessary R1 or R2 resections and operative perforation can be minimized by an understanding of the surgical anatomy, the pattern of spread and difference in operative technique between anorectal excision and a low restorative operation. Surgical technique to maximize R0 resection should be based on a detailed understanding of the pelvic fascia and the levator ani and the use of pre-operative imaging to define lines of excision. With the adoption of even lower restorative resection (intersphincteric) there is a need to reassess the method of anorectal excision. This may be achieved by histopathological assessment of CRM positivity and MDT audit to improve results. Clinical trials are essential.

Surgical treatment of primary locally advanced rectal cancer in Norway

AIMS

Most reports on locally advanced rectal cancer come from specialized centres, with a selected patient material. The purpose of this study was to examine the results after surgical treatment of patients with locally advanced rectal cancer at a population level.

METHODS

National cohort study of 896 patients undergoing surgery for a locally advanced primary adenocarcinoma of the rectum from November 1993 to December 2001.

RESULTS

Surgery with resection was undertaken in 724 patients and 172 patients underwent palliative procedures. Of 557 patients treated for cure, a R0 resection was achieved in 342 (61%). In a multivariate analysis, pre-operative radiotherapy was the only factor with a positive association with R0 status (odds ratio 3.7, 95% confidence interval (CI) 2.1-6.4). Five-year local recurrence rates were 18% (CI 14-23) for R0 resections and 40% (CI 26-52) for R1 resections. Overall 5-year survival rate was 23%; for the group of patients with a R0 resection the survival rate was 49%.

CONCLUSION

The radical resection rate and survival rates in this national study were similar to those reported from specialized centres.

Low rectal cancer: a call for a change of approach in abdominoperineal resection

PURPOSE

Despite the major improvements that have been made due to total mesorectal excision (TME), low rectal cancer still remains a challenge.

METHODS

By investigating a prospective randomized rectal cancer trial in which surgeons had undergone training in TME the factors responsible for the poor outcome were determined and a new method for assessing the quality of surgery was tested.

RESULTS

Survival differed greatly between abdominoperineal resection (APR) and anterior resection (AR; 38.5% v 57.6%, P = .008). Low rectal carcinomas have a higher frequency of circumferential margin involvement (26.5% v 12.6%, P < .001). More positive margins were present in the patients operated with APR (30.4%) compared to AR (10.7%, P = .002). Furthermore, more perforations were present in these specimens (13.7% v 2.5%, P < .001). The plane of resection lies within the sphincteric muscle, the submucosa or lumen in more than 1/3 of the APR cases, and in the remainder lay on the sphincteric muscles.

CONCLUSION

We systematically described and investigated the pathologic properties of low rectal cancer in general, and APR in particular, in a prospective randomized trial including surgeons who had been trained in TME. The poor prognosis of the patients with an APR is ascribed to the resection plane of the operation leading to a high frequency of margin involvement by tumor and perforation with this current surgical technique. The clinical results of this operation could be greatly improved by adopting different surgical techniques and possibly greater use of radiochemotherapy.

Surgery for colorectal cancer in a low-volume unit: assessment of key issues in the achievement of acceptable clinical results

BACKGROUND

The maintenance of modern therapeutic principles requires a proper case load to achieve acceptable surgical results. This may obligate administrative reorganization to overcome these problems and to provide an adequate level of cancer surgery.

AIM

To assess the surgical results of patients coming for surgery for colorectal cancer in a low-volume non-academic unit during the past 15 yr.

METHODS

458 consecutive patients referred for surgery between 1988 and 2001 in Kanta-Häme Central Hospital in Finland were analyzed regarding their disease, mode of surgery, and the immediate and long-term result. The data were collected from patient journals and from the National Centre of Statistics and analyzed in two successive periods.

RESULTS

The number of patients with a localized disease (Dukes A + Dukes B) decreased during the followup from 49% to 45%. A curative procedure was achieved in 68% in the first half and in 73% in the second half of the observation period. The immediate mortality was 5% and 2% in the two periods, respectively. The corrected 5-year survival according to the Dukes Classification was 92% (A), 69% (B), 41% (C ), and 6% (D). In curative surgery for rectal cancer, the incidences of local recurrence decreased from 21% to 9% (NS) and the use of permanent colostomy from 59 to 42% (NS).

CONCLUSIONS

Acceptable immediate and long-term results in curative surgery for colorectal cancer can be achieved in a low-volume surgical unit. Nevertheless, owing to the low volume, the improvement of the results obligates team-based institutional specialization and careful consideration about the extensiveness of the primary procedure in case of cancer obstruction.

Total mesorectal excision for rectal cancer: difference in outcome for low and high rectal cancer

PURPOSE

This prospective study was designed to assess the outcome through the first five years after the introduction of total mesorectal excision in 1993 in a Norwegian central hospital, with special regard to the difference between low (< or =6 cm from anal verge) and high (>6 cm) rectal cancers.

METHODS

A total of 140 patients (81 males; median age, 64 (range, 29-87) years) underwent surgery for rectal cancer under curative intention.

RESULTS

Local recurrence rates were 8 of 44 (18 percent) for the low cancers and 5 of 96 (5 percent) for the high, a statistically significant difference (P = 0.0014). Corresponding numbers when the R1 resections are excluded were 5 of 36 (13 percent) for the low and 4 of 92 (4 percent) for the high cancers (P = 0.002). The five-year survival after R0 resections of cancers <6 cm was significantly reduced compared with those >6 cm. The five-year overall survival for the whole material was 72 percent.

CONCLUSIONS

Surgery alone for rectal cancer can achieve overall good results, with five-year overall survival of 72 percent. The prognosis of the cancers of the lower rectum seems to be inherently different from the tumors of the higher level, both concerning local recurrence and five-year survival, suggesting different biologic behavior of the two cancers.

Prospective, randomized trial examining the role of gentamycin-containing collagen sponge in the reduction of postoperative morbidity in rectal cancer patients: early results and surprising outcome at 3-year follow-up

OBJECTIVE

The study was carried out to evaluate the efficacy of the gentamycin collagen sponge placed in the pelvic cavity after excision of rectal cancer in view of postoperative complications and the risk of cancer recurrence.

METHODS

A total of 229 patients were recruited into the study and randomized into two groups: GRM(+), in which a gentamycin collagen sponge was used, and GRM(-), without the sponge. Tumors were resected using a TME technique. In the GRM(+) group, the sponge was placed into the tumor bed.

RESULTS

Analysis covered 218 patients for whom all follow-up data were available. There were fewer early postoperative complications in the GRM(+) group: 20.7 vs. 37.5%; p=0.044. This effect was found mainly in patients with surgery lasting longer than 3 h. After 36 months' follow-up, the overall survival after R0 resection for the GRM(+) and GRM(-) groups was: 88.66 vs. 73.96%. There was significant reduction in the distant metastasis rate in favor of the GRM(+) group.

CONCLUSION

The use of the gentamycin collagen sponge after excision of rectal cancer is safe and reduces the rate of early postoperative complications. The reasons for the lower rate of distant metastasis in the GRM(+) group are not clear, but the patients enjoy significant survival benefits.