Systematic review of outcomes after intersphincteric resection for low rectal cancer

Sphincter-Preserving Surgery for Low Rectal Cancer: Do We Overshoot the Mark?

PURPOSE

Intersphincteric resection (ISR) is an alternative to abdominoperineal resection (APR) for a selected subset of patients with low rectal cancer, combining equivalent oncological outcome and sphincter preservation. However, functional results are heterogeneous and often imperfect. The aim of the present investigation was to determine the long-term functional results and quality of life after ISR.

METHODS

One hundred forty-three consecutive patients who underwent surgery for low rectal cancer were analysed. Sixty patients received ISR and 83 patients APR, respectively. Kaplan-Meier estimate was used to analyse patients' survival. The EORTC QLQ-C30, -C29 and the Wexner score were used to determine functional outcome and quality of life.

RESULTS

ISR and APR were both associated with comparable morbidity and no mortality. Patients' disease- and recurrence-free survival after ISR and APR were similar (p = 0.2872 and p = 0.4635). Closure of ileostomy was performed in 73% of all patients after ISR. Long-term outcome showed a rate of incontinence (Wexner score ≥10) in 66% of the patients. Despite this, patients' quality of life was significantly better after ISR compared to APR in terms of abdominal complaints and psycho-emotional functioning.

CONCLUSIONS

ISR is technically feasible with acceptable postoperative morbidity rates. Functional results following ISR are compromised by incontinence as the most important complication. However, long-term quality of life is superior to APR, which should be considered when selecting patients for ISR.

Anorectal complications after robotic intersphincteric resection for low rectal cancer

BACKGROUND

Robotic intersphincteric resection (ISR) has been introduced for sphincter-preservation in the treatment of low rectal cancer. However, many patients experience anorectal symptoms and defecatory dysfunction after ISR. This study aims to evaluate the anorectal complications that develop after ISR.

METHODS

The medical records of 108 patients who underwent robotic ISR at Taipei Medical University Hospital, Taipei, Taiwan between December 2011 and June 2016 were retrospectively reviewed. Photographic records of perineal conditions were documented at the following time intervals after surgery: 1 day, 2 weeks, 1, 2, 3 and 6 months. Clinical outcomes and treatment results were analysed.

RESULTS

Eighty-five patients (78.7%) developed edematous hemorrhoids after surgery. These subsided at a median of 56 days after operation (range 23-89 days). Forty-six patients (42.6%) were found to have anal stenosis requiring anal dilatation. Sixteen patients (14.8%) had neorectal mucosal prolapse, which was noted to occur at an average of 98 days after surgery (range 41-162 days). Multivariate analysis showed that the occurrence of edematous hemorrhoids was associated with operating time (P = 0.043), and male gender was a significant risk factor for anal stenosis (P = 0.007).

CONCLUSIONS

This is the first study reporting on the clinical outcomes of anorectal status after robotic ISR. Further studies are needed to assess the long-term effects of these anorectal complications.

Clinical and functional results of laparoscopic intersphincteric resection for ultralow rectal cancer: is there a distinction between the three types of hand-sewn colo-anal anastomosis?

PURPOSE

The purpose of this study is to compare the clinical and functional outcomes of three types of hand-sewn colo-anal anastomosis (CAA) after laparoscopic intersphincteric resection (Lap-ISR) for patients with ultralow rectal cancer.

METHODS

A total of 79 consecutive patients treated by Lap-ISR for low-lying rectal cancer in an academic medical center from June 2011 to February 2016. According to the distal tumor margin and individualized anal length, the patients underwent three types of hand-sewn CAA including partial-ISR, subtotal-ISR, and total-ISR.

RESULTS

Of the 79 patients, 35.4% required partial-ISR, 43% adopted subtotal-ISR, and 21.5% underwent total-ISR. R0 resection was achieved in 78 patients (98.7%). In addition to distal resection margin, there were no significant differences in clinicopathological parameters and postoperative complications between the three groups. The type of hand-sewn CAA did not influence the 3-year disease-free survival (DFS) or local relapse-free survival (LFS). At 24-months follow-up, in spite of higher incontinence scores in total-ISR group, there were not statistically significant differences in functional outcomes including Wexner score or Kirwan grade between the groups. Nevertheless, patients with chronic anastomotic stricture showed worse anal function than those without the complication.

CONCLUSION

The type of hand-sewn CAA after Lap-ISR may not influence oncological and functional outcomes, but chronic stricture deteriorates continence status.

On a prolonged interval between rectal cancer (chemo)radiotherapy and surgery

Preoperative radiotherapy (RT) or chemoradiotherapy (CRT) is often required before rectal cancer surgery to obtain low local recurrence rates or, in locally advanced tumours, to radically remove the tumour. RT/CRT in tumours responding completely can allow an organ-preserving strategy. The time from the end of the RT/CRT to surgery or to the decision not to operate has been prolonged during recent years. After a brief review of the literature, the relevance of the time interval to surgery is discussed depending upon the indication for RT/CRT. In intermediate rectal cancers, where the aim is to decrease local recurrence rates without any need for down-sizing/-staging, short-course RT with immediate surgery is appropriate. In elderly patients at risk for surgical complications, surgery could be delayed 5-8 weeks. If CRT is used, surgery should be performed when the acute radiation reaction has subsided or after 5-6 weeks. In locally advanced tumours, where CRT is indicated, the optimal delay is 6-8 weeks. In patients not tolerating CRT, short-course RT with a 6-8-week delay is an alternative. If organ preservation is a goal, a first evaluation should preferably be carried out after about 6 weeks, with planned surgery for week 8 if the response is inadequate. In case the response is good, a new evaluation should be carried out after about 12 weeks, with a decision to start a 'watch-and-wait' programme or operate. Chemotherapy in the waiting period is an interesting option, and has been the subject of recent trials with promising results.

Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis

AIM

The aim was to evaluate the association of neoadjuvant therapy with increases in the incidence of anastomotic leakage (AL) after middle and low rectal anterior resection.

METHOD

The electronic databases of PubMed, Web of Science, Scopus and Ovid were searched between 1980 and 2015. The random effects model was used to model the pooled data to determine the odds ratio with 95% confidence interval. Heterogeneity was evaluated using the Q test and I² statistics. Subgroup, sensitivity and meta-regression analysis was conducted to explore heterogeneity.

RESULTS

Neoadjuvant therapy was not shown to increase the incidence of postoperative AL as demonstrated by an OR of 1.16 [95% CI 0.99-1.36; P = 0.07 (random effects model)]. The subgroup analysis of neoadjuvant radiotherapy using the random effects model suggested that it did not increase the rate of postoperative AL (OR = 1.24, 95% CI 0.97-1.58; P = 0.08). The subgroup analysis of neoadjuvant chemoradiotherapy indicated that the rate of postoperative AL again did not increase with an OR = 1.06 [95% CI 0.86-1.30; P = 0.59 (random effects model)]. The interval to surgery after neoadjuvant therapy and preoperative radiotherapy (short or long course) was not associated with an increased incidence of postoperative AL.

CONCLUSION

Neoadjuvant therapy does not appear to increase the incidence of postoperative AL after anterior resection for mid and low rectal cancer. In addition, neither the interval to surgery after neoadjuvant therapy nor the radiotherapy regimen increases the rate of postoperative AL.

Intersphincteric resection for low rectal cancer

For low rectal cancer located < 5 cm from the anal verge, abdominoperineal resection (APR) with permanent sigmoid colostomy is usually used to ensure the R0 resection. Sphincter saving surgery has emerged in the last 20 years, and the introduction of intersphincteric resection (ISR) can successfully preserve the anal function and guarantee a radical tumor resection for patients with ultra-low lying tumors. Therefore, the use of APR has been consistently declining worldwide. Recently, a growing body of research on ISR has been reported. However, more evidence based results are needed to clarify some issues about ISR. In the current review, we discuss the indications for ISR and the oncological and functional outcomes following the procedure. Some technique issues of ISR are also discussed.

Colonic prolapse after intersphincteric resection for very low rectal cancer: a report of 12 cases

BACKGROUND

There are no published data concerning management of patients with exteriorized colonic prolapse (CP) after intersphincteric rectal resection (ISR) and side-to-end coloanal manual anastomosis (CAA) for very low rectal cancer. The aim of the present study was to report our experience in 12 consecutive cases of CP following ISR with CAA.

METHODS

From 2006 to 2014, all patients with very low rectal cancer who developed CP after ISR and CAA were reviewed. Demographic and surgical data, prolapse symptoms and treatment were recorded. Postoperative morbidity, functional outcomes and results after prolapse surgery were recorded.

RESULTS

Twelve out of 143 patients (8 %) who underwent ISR with side-to-end CAA for low rectal cancer presented CP: 7/107 ISR (7 %) with partial resection of the internal anal sphincter (IAS) and 5/36 ISR (14 %) with subtotal or total resection of the IAS (NS). CP was diagnosed after a median of 6 months (range 2-72 months) after ISR. All patients with CP suffered from pain and fecal incontinence. Median Wexner fecal incontinence score before surgery was 16.5 (range 12-20). Three patients refused reoperation. Nine patients underwent transanal surgery with prolapse resection (including colonic stump and side-to-end anastomosis) and new end-to-end CAA (with posterior myorraphy in 4 cases). After a median follow-up of 30 months (range 8-87 months), 3/9 patients (33 %) had CP recurrence: One with very poor function was treated by abdominoperineal resection and definitive stoma. The 2 others were successfully reoperated on transanally. Median Wexner fecal incontinence score after CP surgery was 9 (range 0-20). No CP recurrence was noted for the 6 other patients, and function improved in all cases. Thus, at the end of follow-up, 8/9 patients (89 %) had no recurrence after surgery.

CONCLUSIONS

We believe surgery must be attempted in these patients who develop CP after ISR with CAA for very low rectal cancer in order to improve function and symptoms. A transanal approach with CP resection and new end-to-end anastomosis appeared to be safe and effective. Larger studies are needed to confirm our results.

Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique: A systematic review

INTRODUCTION

The Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique utilises a perineal incision to facilitate resection of the distal rectum. The aim of this study was to review use of the APPEAR technique, assessing patient selection, indications, complications and outcomes, both oncological and functional.

MATERIALS AND METHODS

A systematic review was carried out to identify studies reporting outcomes following rectal resection via an anterior perineal incision, with no limits on year or language. All studies were included. Quality of studies was assessed using the methodological index for non-randomised studies (MINORS) score.

RESULTS

Thirteen studies were identified from 1985 to 2013. 174 patients (102 male), ranging from 21 to 82 years, underwent surgery at eleven centres in seven countries. Maximum experience at one centre is 60 cases. 9 cases were performed for rectal dysplasia, 141 for rectal cancer; 96 resections were R0 (remaining 45 unstated). 14 cases were carried out laparoscopically. 30-day mortality was 2.3% (4 patients); there were 2 further deaths from systemic recurrence. Permanent stoma rate was 8/155 (5%). The most frequent complication was perineal or vaginal fistulation (26 patients): 6 underwent reoperation; 15 healed with conservative management; 5 required a permanent stoma. Functional outcomes were variably reported; median stool frequency was 3/24hrs with average Wexner scores of 5-5.5.

CONCLUSION

In selected patients the APPEAR technique offers avoidance of permanent colostomy with good oncological outcomes. The majority of studies had short follow up periods and longer-term outcomes will need evaluation.

Topographic Anatomy of the Anal Sphincter Complex and Levator Ani Muscle as It Relates to Intersphincteric Resection for Very Low Rectal Disease

BACKGROUND

Intersphincteric resection has become a widely used treatment for patients with rectal cancer. However, the detailed anatomy of the anal canal related to this procedure has remained unclear.

OBJECTIVE

The purpose of this study was to clarify the detailed anatomy of the anal canal.

DESIGN

This is a descriptive study.

SETTINGS

Histologic evaluations of paraffin-embedded tissue specimens were conducted at a tertiary referral hospital.

PATIENTS

Tissue specimens were obtained from cadavers of 5 adults and from 13 patients who underwent abdominoperineal resection for rectal cancer.

MAIN OUTCOME MEASURES

Sagittal sections from 9 circumferential portions of the cadaveric anal canal (histologic staining) and 3 circumferential portions from patients were studied (immunohistochemistry for smooth and skeletal muscle fibers).

RESULTS

Longitudinal fibers between the internal and external anal sphincters consisted primarily of smooth muscle fibers that continued from the longitudinal muscle of the rectum. The levator ani muscle attached directly to the lateral surface of the longitudinal smooth muscle of the rectum. The length of the attachment was longer in the anterolateral portion and shorter in the posterior portion of the anal canal. In the lateral and posterior portions, the levator ani muscle partially overlapped the external anal sphincter; however, there was less overlap in the anterolateral portion. In the posterior portion, thick smooth muscle was present on the surface of the levator ani muscle and it continued to the longitudinal muscle of the rectum.

LIMITATIONS

We observed only limited portions in some surgical specimens because of obstruction by tumors.

CONCLUSIONS

The levator ani muscle attaches directly to the longitudinal muscle of the rectum. The spatial relationship between the smooth and skeletal muscles differed in different portions of the anal canal. For intersphincteric resection, dissection must be performed between the longitudinal muscle of the rectum and the levator ani muscle/external anal sphincter, and the appropriate surgical lines must be selected based on the specific structural characteristics of each portion.

A Systematic Review of Outcomes After Transanal Mesorectal Resection for Rectal Cancer

BACKGROUND

Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer.

OBJECTIVE

The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection.

DATA SOURCES

The Cochrane Library, PubMed, and MEDLINE databases were reviewed.

STUDY SELECTION

Systematic review of the literature from January 2005 to September 2015 was used for study selection.

INTERVENTION

Intervention included transanal mesorectal resection for rectal cancer.

MAIN OUTCOME MEASURES

Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured.

RESULTS

Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies.

LIMITATIONS

A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables.

CONCLUSIONS

Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.

Laparoscopic intersphincteric resection: indications and results

Surgical treatment of distal rectal cancer has long been based only on abdominoperineal excision, resulting in a permanent stoma and not always offering a definitive local control. Sphincter saving surgery has emerged in the last 20 years and can be offered also to patients with low lying tumours, provided that the external sphincter is not involved by the disease. An intersphincteric resection (ISR) is based on the resection of the rectum with a distal dissection proceeding into the space between the internal and the external anal sphincter. Originally described as an open procedure, it has also been developed with the laparoscopic approach, and also this technically demanding procedure is inscribed among those offered to the patient by a minimally invasive surgery. Indications have to be strict and patient selection is crucial to obtain both oncological and functional optimal results. The level of distal dissection and the extent of internal sphincter resected are chosen according to the distal margin of the tumour and is based on MRI findings: accurate imaging is therefore mandatory to better define the surgical approach. We here present our actual indications for ISR, results in terms of operative time, median hospital stay for ISR in our experience and review the updated literature.

Functional results of robotic total intersphincteric resection with hand-sewn coloanal anastomosis

BACKGROUND

In recent decades there has been an increasing trend toward sphincter-preserving procedures for the treatment of low rectal cancer. Robotic surgery is considered to be particularly beneficial when operating in the deep pelvis, where laparoscopy presents technical limitations. The aim of this study was to prospectively evaluate the functional outcomes in patients affected by rectal cancer after robotic total intersphincteric resection (ISR) with hand-sewn coloanal anastomosis.

METHODS AND PROCEDURES

From March 2008 to October 2012, 23 consecutive patients affected by distal rectal adenocarcinoma underwent robotic ISR. Operative, clinical, pathological and functional data regarding continence or presence of a low anterior resection syndrome (LARS) were prospectively collected in a database.

RESULTS

Twenty-three consecutive patients were included in the study: 8 men and 15 women. The mean age was 60.2 years (range 28-73). Eighteen (78.3%) had neoadjuvant radiochemotherapy. Conversion rate was nil. The mean operative time was 296.01 min and the mean postoperative hospital stay was 7.43 ± 1.73 days. According to Kirwan's incontinence score, good fecal continence was shown in 85.7% of patients (Grade 1 and 2) and none required a colostomy (Grade 4). Concerning LARS score, the results were as follows: 57.1% patients had no LARS; 19% minor LARS and 23.8% major LARS.

CONCLUSIONS

Robotic total ISR for low rectal cancer is an acceptable alternative to traditional procedures. Extensive discussion with the patient about the risk of poor functional outcomes or LARS syndrome is mandatory when considering an ISR for treatment of low rectal cancer.

Hand-sewn coloanal anastomosis for low rectal cancer: technique and long-term outcome

AIM

This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer.

METHOD

Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 (supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision).

RESULTS

Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival.

CONCLUSION

CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients.

Outcomes of ultra-low anterior resection combined with or without intersphincteric resection in lower rectal cancer patients

PURPOSE

We evaluated the current practice of ultra-low anterior resection (uLAR) in patients with lower rectal cancer and compared uLARs using mostly transabdominal approach with or without intersphincteric resection (ISR).

METHODS

A total of 624 consecutive lower rectal cancer patients undergoing curative uLAR were prospectively enrolled as ISR+ vs. ISR- groups (329 vs. 295 patients) between 2005 and 2012. The ISR+ group additionally received levator-sphincter reinforcement after distal resection.

RESULTS

The circumferential resection margin (CRM) + rate (≤1 mm) was 2.1 % in the two groups. Postoperative ileus occurred more in the ISR- group than in the ISR+ group (p = 0.02). Substantial erectile dysfunction occurred 1.8 times more frequently in the ISR- group than in the ISR+ group (32 vs. 18.1 %; p = 0.01) among male patients at 2 years postoperatively. The urge to defecate volume and maximal tolerance volume, closely correlated with maximal squeezing pressure and/or mean resting pressure, did not differ between patients with and without chemoradiotherapy until 24 months postoperatively. Nevertheless, the urge to defecate volume was lesser in the ISR- group than in the ISR+ group at 24 months postoperatively (p = 0.022). For 301 patients in which >5 years had elapsed postoperatively, the mean 5-year local recurrence rate was 4.3 %, and the 5-year disease-free and overall survival rates were 78.9 and 92 %, respectively, without differences between the two groups.

CONCLUSIONS

Compared with uLAR without ISR, the transabdominal ISR with levator-sphincter reinforcement provides a safe resection plane with competent CRM, concurrently reduces substantial complications, and marginally promotes recovery of neorectal function.

Multicentre study of robotic intersphincteric resection for low rectal cancer

BACKGROUND

There is a lack of information regarding the oncological safety of robotic intersphincteric resection (ISR) with coloanal anastomosis. The objective of this study was to compare the long-term feasibility of robotic compared with laparoscopic ISR.

METHODS

Between January 2008 and May 2011, consecutive patients who underwent robotic or laparoscopic ISR with coloanal anastomosis from seven institutions were included. Propensity score analyses were performed to compare outcomes for groups in a 1 : 1 case-matched cohort. The primary endpoint was 3-year disease-free survival.

RESULTS

A total of 334 patients underwent ISR with coloanal anastomosis, of whom 212 matched patients (106 in each group) formed the cohort for analysis. The overall rate of conversion to open surgery was 0.9 per cent in the robotic ISR group and 1.9 per cent in the laparoscopic ISR group. Nine patients (8.5 per cent) in the laparoscopic group and three (2.8 per cent) in the robotic ISR group still had a stoma at last follow-up (P = 0.075). Total mean hospital costs were significantly higher for robotic ISR (€ 12,757 versus € 9223 for laparoscopic ISR; P = 0.037). Overall 3-year local recurrence rates were similar in the two groups (6.7 per cent for robotic and 5.7 per cent for laparoscopic resection; P = 0.935). The combined 3-year disease-free survival rates were 89.6 (95 per cent c.i. 84.1 to 95.9) and 90.5 (85.4 to 96.6) per cent respectively (P = 0.298).

CONCLUSION

Robotic ISR with coloanal anastomosis for rectal cancer has reasonable oncological outcomes, but is currently too expensive with no short-term advantages.

Organ preservation in rectal cancer: current status and future perspectives

With the introduction of population screening initiatives, more patients may be amenable to local, transanal excision (LE) of early-stage rectal cancer. The most important drawback of LE is the risk of understaging node-positive disease. The most powerful predictors of node-positive disease are lymphatic invasion, submucosal invasion depth and width, tumor budding and poor differentiation. Therefore, LE should be reserved for low-risk T1 tumors in those reluctant or unable to undergo major surgery. Neoadjuvant chemoradiation followed by LE for T2 tumors allows adequate local control, and is currently being compared with anterior resection alone in randomized trials. A mere watchful waiting approach has been proposed in clinical complete responders to chemoradiation. However, given the very poor accuracy of current imaging modalities to predict a true pathological complete response, this strategy should not be offered outside of well-controlled trials.

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.

Factors affecting sphincter-preserving resection treatment for patients with low rectal cancer

The aim of the present study was to identify the factors associated with the use of sphincter-preserving resection (SPR) surgery for the treatment of low rectal cancer. A total of 330 patients with histopathologically confirmed low rectal cancer were divided into two groups, namely the abdominoperineal resection (APR) and sphincter-preserving (SP) groups. For SPR factor analysis, the χ² test was performed as the univariate analysis, while a logistic regression test was conducted as the multivariate analysis. Of the 330 patients, 192 cases (58.18%) received SPR surgery and 138 cases (41.82%) underwent an APR. Univariate analysis results revealed that the sphincter-preserving factor was significantly associated with age, gender, ethnicity, body mass index (BMI), total infiltrated circumference, distance of the tumor from the anal verge (DTAV), depth of invasion and tumor grade (P<0.05). However, there were no statistically significant associations with family medical history, diabetes history, venous tumor embolism, growth type, tumor length, lymphatic metastasis and level of preoperative carcinoembryonic antigen (P>0.05). Multivariate analysis indicated that the sphincter-preserving factor was strongly associated with DTAV and the depth of invasion, with significant statistical difference (P<0.05). Therefore, selecting SPR surgery for patients with low rectal cancer is dependent on age, gender, ethnicity, BMI, the total infiltrated circumference, DTAV, depth of invasion and tumor grade. In addition, DTAV and the depth of invasion are independent risk factors for the selection of SPR surgery.

Toward the end of abdominoperineal resection for rectal cancer? An 8-year experience in 189 consecutive patients with low rectal cancer

OBJECTIVES

To assess whether recent advances, such as intersphincteric resection (ISR) or local excision (LE) if a suspicion of complete tumor response after radiochemotherapy (RCT), could have modified the rate of end stoma (ES) in low rectal cancer treatment.

BACKGROUND

ES rate remains around 30% to 50% in patients with low rectal cancer.

METHODS

From 2005 to 2013, all patients with low rectal cancer undergoing laparoscopic total mesorectal excision, with or without neoadjuvant RCT, and patients undergoing LE after RCT were included.

RESULTS

A total of 189 patients presented a low rectal cancer; 162 (86%) underwent RCT; total mesorectal excision was performed in 172 (90%), followed by stapled colorectal anastomosis (n=26; 15%), manual coloanal anastomosis with partial (n=92; 53%) or total ISR (n=32; 19%), or ES that included abdominoperineal resection (n=21; 12%) and low Hartmann procedure (n=1; 1%). LE after RCT was performed in 19 of 189 (10%) patients with a suspicion of complete tumor response. Among them 2 of 19 (11%) underwent immediate secondary total mesorectal excision (1 abdominoperineal resection and 1 coloanal anastomosis with total ISR) because of poor pathological criteria.

CONCLUSIONS

Management of rectal cancer with colorectal anastomosis and coloanal anastomosis with partial ISR allowed to obtain a 38% ES rate (71/189); the additional use of total ISR decreased this rate to 22% (39/189). Selective use of LE reduced this rate to only 12% (22/189). Nowadays, recent advances lead to a paradigm shift, with only 12% ES rate in low rectal cancer.

Improvement of fecal incontinence and quality of life by electrical stimulation and biofeedback for patients with low rectal cancer after intersphincteric resection

OBJECTIVE

To assess the efficacy and benefits of pelvic rehabilitation programs in terms of functional outcomes and quality of life for patients with fecal incontinence and defecation disorders after rectal cancer surgery.

DESIGN

Prospective, observational study.

SETTING

University hospital physiotherapy clinics.

PARTICIPANTS

Patients (N=32) who experienced fecal incontinence after sphincter-saving surgery with the intersphincteric resection (ISR) technique and could follow and cooperate with the treatment schedule were included in the present study.

INTERVENTIONS

Pelvic rehabilitation programs included electrical stimulation (ES) and biofeedback (BF).

MAIN OUTCOME MEASURES

Functional results, Wexner score, and anorectal manometry were used to assess the clinical outcomes of rehabilitation treatment.

RESULTS

Maximum squeeze pressure improved after rehabilitation training (P=.014). There were no statistical differences in resting pressure, resting muscle electromyography, and maximum squeeze electromyography (P=.061, P=.76, and P=.99, respectively). The mean stool frequency was 18.8 per 24 hours before the pelvic intervention program and 7.8 per 24 hours after ES and BF training (P<.001). Of the 32 patients, 27 required antidiarrheal medications before treatment, and after completion of the training, only 9 patients still needed antidiarrheal medications (P<.001). Significant improvements were observed in the Wexner score (17.74 vs 12.93; P<.001).

CONCLUSIONS

Our data show that ES and BF are effective in the treatment of fecal incontinence, leading to improvement of quality of life for patients with low rectal cancer after ISR.

Flattened tumor requires a more careful attention for residual distal cancer spread in locally advanced lower rectal carcinoma after chemoradiotherapy

BACKGROUND/AIMS

Limited data are available on distal resection margin (DRM) for lower rectal cancer (LRC) after preoperative chemoradiotherapy (pre-CRT); thus, we aimed to establish the criteria for DRMs as estimated by the macroscopic tumor appearance.

METHODS

This was a pathological study using whole-mount sections that included the entire circumference of tumor. Residual cancer spread located most distally from the macroscopic tumor border was mainly evaluated.

RESULTS

A retrospective cohort of 42 consecutive patients with locally advanced LRC after pre-CRT was enrolled, and 38 patients were eligible for this study. According to the macroscopic tumor appearance, 18 patients had raised-type and 20 had flattened-type tumors. Patients with flattened-type tumors were closely associated with histopathological regression grade. Residual distal cancer spread (RDCS) was located ≤4.0 mm (median, 0.1 mm) in the raised-type tumors and ≤17.1 mm (median, 4.2 mm) in the flattened-type tumors. RDCS in flattened-type tumors was distributed diffusely and distally from the tumor border (p = 0.022).

CONCLUSION

Even in patients evaluated as pre-CRT responders, flattened tumors often accompanied distally located residual cancer that had spread from the tumor border and require more careful attention in order to ensure cancer clearance.

Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome

BACKGROUND

Traditionally, conventional intersphincteric resection requires a combined abdominal and perineal approach and a handsewn coloanal anastomosis procedure, which is difficult to accomplish via the perineal approach. A completely abdominal approach partial intersphincteric resection (APISR) with laparoscopy can simplify the anastomosis procedure. This study evaluated the intermediate-term oncological and functional results of laparoscopic versus open APISR for low rectal cancer.

METHODS

A total of 137 consecutive patients with low rectal cancer who underwent APISR from January 2006 to August 2013 were retrospectively evaluated. Patient groups were classified into as open surgery (OP, n = 48) group and laparoscopy (LAP, n = 89). The primary endpoint was 3-year disease-free survival and the Wexner score for anal function.

RESULTS

The LAP group had longer operating time, less intraoperative blood loss, and shorter hospital stay after surgery compared with the OP group. Median follow-up was 32.3 months. The local recurrence rates were similar in the two groups (LAP 3.2% vs. OP 6.1%; P = 0.652). The combined 3-year disease-free survival rate was 83.2% in the LAP group and 83.8% in the OP group (P = 0.857). Wexner scores were similar in the two groups (LAP 2.9 ± 4.5 vs. OP 3.1 ± 5.0). In the LAP group, 89.7% of patients had good continence compared with 91.4% in the OP group (P = 0.311).

CONCLUSIONS

Laparoscopic APISR can be performed safely and offers similar intermediate-term oncological and functional outcome compared with the open procedure. The oncological adequacy requires long-term follow-up data.

Expression and significance of DOK2 in colorectal cancer

A reduction in the levels of docking protein 2 (DOK2) expression has previously been reported in lung adenocarcinoma and gastric cancer, indicating that this protein acts as a tumor suppressor in solid tumors. The aim of the current study was to determine the significance of DOK2 in colorectal cancer. The study consisted of 102 patients who underwent curative surgery for colorectal cancer. Histopathological and immunohistochemical analysis of DOK2 protein expression levels was performed in issue samples, and univariate and multivariate analyses were used to investigate the correlation between prognosis and the clinicopathological parameters. DOK2 expression was confirmed in the normal colorectal mucosa tissues, which is consistent with the literature, whereas 34 out of 102 (33.3%) tumor specimens were negative. The results revealed that recurrence was more likely to develop in DOK2(-) patients compared with DOK2(+) patients. The DOK2(-) patients also exhibited a poorer five-year overall survival rate (59.1%) compared with the DOK2(+) group (76.4%; P=0.0328). These results indicate that DOK2 may potentially be used as a marker of poor prognosis in patients with colorectal cancer following curative resection.

Surgical strategy for low rectal cancers

The two goals of surgery for lower rectal cancer surgery are to obtain clear "curative" margins and to limit post-surgical functional disorders. The question of whether or not to preserve the anal sphincter lies at the center of the therapeutic choice. Histologically, tumor-free distal and circumferential margins of>1mm allow a favorable oncologic outcome. Whether such margins can be obtained depends of TNM staging, tumor location, response to chemoradiotherapy and type of surgical procedure. The technique of intersphincteric resection relies on these narrow margins to spare the sphincter. This procedure provides satisfactory oncologic outcome with a rate of circumferential margin involvement ranging from 5% to 11%, while good continence is maintained in half of the patients. The extralevator abdominoperineal resection provides good oncologic results, however this procedure requires a permanent colostomy. A permanent colostomy alters several domains of quality of life when located at the classical abdominal site but not when brought out at the perineal site as a perineal colostomy.

Completely abdominal intersphincteric resection for lower rectal cancer: feasibility and comparison of robot-assisted and open surgery

BACKGROUND

Most previous studies of intersphincteric resection (ISR) adopted a two-stage procedure involving abdominal and transanal approaches. We performed completely abdominal ISR via open and a robot-assisted (RA) approaches as treatments for lower rectal cancer (LRC). The RA approach might enable deep dissection and facilitate ISR in patients with restrictive pelvic anatomy.

METHODS

A consecutive cohort of 222 LRC patients who underwent completely abdominal ISR (RA ISR, n = 108; open ISR, n = 114) was enrolled prospectively, and their short-term outcomes were evaluated.

RESULTS

In a multivariate analysis, ISR was performed more frequently in the RA than in the open group (82.6 vs. 67.9 %, p = 0.008). The number of harvested lymph nodes was >12 in both groups. A positive distal resection margin was not observed in either group, and a positive circumferential resection margin was found in one patient in the RA group. Overall morbidity did not differ between the groups. Moderate to severe sexual dysfunction occurred 2.7-fold more frequently in the open group (p = 0.023) among male patients ≤65 years. Mean Wexner's fecal incontinence scores at postoperative months 6 and 12 were greater in the open group than in the RA group (p < 0.05).

CONCLUSIONS

Completely abdominal ISR may be feasible in the treatment of LRC, based on a short-term study. Furthermore, RA ISR had equivalent oncological outcomes and slightly improved functional recovery relative to open ISR.

Multidisciplinary treatment of rectal cancer in 2014: where are we going?

In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.

Overview of radiation therapy for treating rectal cancer

A major outcome of importance for rectal cancer is local control. Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce the local recurrence rate. Nowadays, the local recurrence rate has been reduced because of both good surgical techniques and the addition of radiotherapy. Based on recent reports in the literature, preoperative chemoradiotherapy is now considered the standard of care for patients with stages II and III rectal cancer. Also, short-course radiotherapy appears to provide effective local control and the same overall survival as more long-course chemoradiotherapy schedules and, therefore, may be an appropriate choice in some situations. Capecitabine is an acceptable alternative to infusion fluorouracil in those patients who are able to manage the responsibilities inherent in self-administered, oral chemotherapy. However, concurrent administration of oxaliplatin and radiotherapy is not recommended at this time. Radiation therapy has long been considered an important adjunct in the treatment of rectal cancer. Although no prospective data exist for several issues, we hope that in the near future, patients with rectal cancer can be treated by using the best combination of surgery, radiation therapy, and chemotherapy in near future.

Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

BACKGROUND

Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

DISCUSSION

Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Long-term outcomes after intersphincteric resection for low-lying rectal cancer

BACKGROUND

As an anus-preserving surgery for very low rectal cancer, intersphincteric resection (ISR), has advanced markedly over the last 20 years. We investigated long-term oncologic, functional, and quality of life (QOL) outcomes after ISR with or without partial external sphincter resection (PESR).

METHODS

A series of 199 patients underwent curative ISR with or without PESR between 2000 and 2008, with 49 receiving preoperative chemoradiotherapy (CRT group) and 150 undergoing surgery first (surgery group). Overall survival (OS), disease-free survival (DFS), and local relapse-free survival (LFS) rates were calculated using Kaplan-Meier methods. Functional outcomes were assessed using the Wexner incontinence score. QOL was investigated using the Short-Form 36 questionnaire (SF-36) and modified fecal incontinence quality of life (mFIQL) scale.

RESULTS

After a median follow-up of 78 months (range 12-164 months), estimated 7-year OS, DFS, and LFS rates were 78, 67, and 80 %, respectively. LFS was better in the CRT group than in the surgery group (p = 0.045). Patients with PESR or positive circumferential resection margins showed significantly worse survival. The median Wexner incontinence score at >5 years was 8 in the surgery group and 10 in the CRT group (p = 0.01). QOL was improved in all physical and mental subscales of the SF-36 at >5 years. Although the mFIQL showed a relatively good score in all groups at >5 years, a significant difference existed between the CRT and surgery groups (p = 0.008).

CONCLUSIONS

With long-term follow-up, oncologic, functional, and QOL results after ISR appear acceptable, although CRT is associated with disturbance.

What should we intend for minimally invasive treatment of colorectal cancer?

Non-inferiority of laparoscopic treatment of colorectal cancer (CRC) has been demonstrated in randomized controlled trials although operative and perioperative management varies widely among centers. Literature data in English language published up to April 15, 2014 were analyzed in order to give an up to date analysis that would highlights the key aspects of a modern and factual minimally invasive treatment of CRC. Laparoscopic resection is the first choice treatment of colon cancer. Laparoscopic resection of rectal cancer should be considered an investigational procedure to be performed in high volume centers with special interest in laparoscopy and colorectal surgery. Less invasive approaches should be taken into account with the aim of reducing surgical stress. The adoption of ERAS programs has demonstrated to optimize short-term results. Future research should be directed to prove possible long-term advantages, in terms of overall and disease-free survival, of minimally invasive treatment of CRC.

Multicenter Evaluation of Rectal cancer ReImaging pOst Neoadjuvant (MERRION) Therapy

OBJECTIVE

The aim of this study was to evaluate the utility of reimaging rectal cancer post-CRT (chemoradiotherapy) with magnetic resonance (MR) imaging of the pelvis for local staging and computed tomography of thorax, abdomen, and pelvis (CT TAP) to identify distant metastases.

BACKGROUND

The success of neoadjuvant CRT for locally advanced rectal cancer has changed an already complex management algorithm. There is no consensus whether patients should be restaged before surgery.

METHODS

Data from 5 institutions with prospectively maintained databases including patients who received neoadjuvant CRT for locally advanced rectal cancer were acquired. Only patients who had been staged pre- and post-CRT with MR imaging and CT TAP were included. MR findings were correlated with histopathological stage using weighted κ (kappa) statistics to test agreement, where a κ value of less than 0.5 was deemed unacceptable.

RESULTS

A total of 285 patients fulfilled the criteria for the study; 84% had American Joint Committee for Cancer stage 3 disease pre-CRT, and the remainder had stage 2 disease. Fourteen patients did not proceed to surgery post-CRT-2 were observed as "complete responders," and the remainder either had unresectable disease or were unfit for surgery. MR imaging could not predict T stage (κ = 0.212) or nodal involvement (κ = 0.336). Most pertinently, MR imaging was unable to detect a complete pathological response (κ = 0.021), nor could it discriminate T4 disease (κ = 0.445). CT TAP restaging altered management in 6.7% of patients, who had metastatic disease.

CONCLUSIONS

MR reimaging using standard protocols is of limited value in determining surgical approaches; a better modality of local restaging is required.

Laparoscopic intersphincteric resection for low rectal cancer: comparison of stapled and manual coloanal anastomosis

AIM

The study aim was to analyse the safety and feasibility of laparoscopic intersphincteric resection with stapled coloanal anastomosis for low rectal cancer.

METHOD

Between March 2009 and August 2010, 22 patients underwent laparoscopic intersphincteric resection with a stapled coloanal anastomosis without a diverting ileostomy. The results were compared retrospectively with hand-sewn coloanal anastomoses performed between January 2001 and May 2009, which included 55 open and 38 laparoscopic intersphincteric resections. The morbidity comparison only included data relevant to the anastomosis. Function was compared using the Saito function questionnaire and the Wexner score and only involved data relevant to the laparoscopy.

RESULTS

The anastomotic complication rates were similar for fistula, bleeding and neorectal mucosal prolapse (P = 0.526, P = 0.653 and P = 0.411, respectively). Anastomotic leakage and stricture formation of the stapled coloanal anastomosis were significantly lower than those of the hand-sewn coloanal anastomosis (P = 0.037 and P = 0.028, respectively). There were no significant differences in the Saito function questionnaire and the Wexner score between the stapled and hand-sewn coloanal anastomotic groups (all P > 0.05).

CONCLUSION

Laparoscopic intersphincteric resection with a stapled coloanal anastomosis is technically feasible and is less likely to result in anastomotic leakage and stricture formation than a hand-sewn anastomosis.

Does anastomotic leakage impair functional results and quality of life after laparoscopic sphincter-saving total mesorectal excision for rectal cancer? A case-matched study

PURPOSE

Anastomotic leakage (AL) after total mesorectal excision (TME) for rectal cancer is suspected to alter function. However, very few reports have been devoted to this problem. The aim of this study was to assess the influence of AL on function and quality of life (QoL) after laparoscopic TME for cancer.

METHODS

A total of 170 patients who underwent laparoscopic TME and sphincter-saving surgery for mid and low rectal cancer were included (67 % after neoadjuvant chemoradiotherapy). Twenty-one patients with AL were assessed for function and QoL (Short Form 36 (SF-36), Fecal Incontinence Quality of Life (FIQL), CR-29, and Wexner's score) at the most recent follow-up. These patients were matched to 42 patients without AL according to sex, body mass index, ypTNM, radiotherapy, and type of anastomosis.

RESULTS

After a median follow-up of 30 months, AL significantly impaired physical activity (SF-36) (p = 0.004), self-respect (FIQL) (p = 0.029), wear pad's score (Wexner's score) (p = 0.043), and blood and mucus in stool score (CR-29) (p = 0.001). Overall Wexner's score did not show any significant difference in the two groups, 8.9 in AL patients vs. 11.6 in patients without AL (p = 0.1).

CONCLUSION

AL significantly impairs both functional results and quality of life after laparoscopic sphincter-saving TME for rectal cancer. However, the observed difference was only limited, leading to similar outcomes on most of the tested scores. Patients with AL should be warned that if they initially experience severely impaired results, outcomes tend with time to become similar to those observed in noncomplicated patients.

Smooth muscle enfoldment internal sphincter construction after intersphincteric resection for rectal cancer

Objective

To assess smooth muscle enfoldment and internal sphincter construction (SMESC) for improvement of continence after intersphincteric resection (ISR) for rectal cancer.

Methods

Twenty-four Bama miniature pigs were randomly divided into a conventional ISR group and experimental SMESC group, with 12 pigs in each group. The proximal sigmoid colon was anastomosed directly to the anus in the ISR group. In the SMESC group, internal sphincter construction was performed. At 12 weeks before and after surgery, rectal resting pressure and anal canal length were assessed. Three-dimensional ultrasound was used to determine the thickness of the internal sphincter. After the animals were sacrificed, the rectum and anus were resected and pathological examinations were performed to evaluate the differences in sphincter thickness and muscle fibers.

Results

All 24 animals in the SMESC group and the ISR group survived the surgery. Twelve weeks post-surgery, the rectal resting pressure, length of the anal high-pressure zone and the postoperative internal sphincter thickness for the ISR group were significantly lower than for the SMESC group. There was a thickened area (about 2 cm) above the anastomotic stoma among animals from the SMESC group; in addition, the smooth muscles were significantly enlarged and enfolded when compared to the ISR group.

Conclusion

This animal model study shows that the SMESC procedure achieved acceptable reconstruction of the internal anal neo-sphincter (IAN/S), without increasing surgical risk. However, the findings in this experimental animal model must be confirmed by clinical trials to determine the safety and efficacy of this procedure in clinical practice.

Serotonin (5-HT3) receptor antagonists for the reduction of symptoms of low anterior resection syndrome

Purpose

Serotonin (5-hydroxytryptamine [5-HT])₃ receptor antagonists are effective for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D), in which exaggerated intestinal/colonic hypermotility is often observed. Recent studies have suggested that the motility disorder, especially spastic hypermotility, seen in the neorectum following sphincter-preserving operations for rectal cancer may be the basis of the postoperative defecatory malfunction seen in these patients. We investigated the efficacy of 5-HT₃ receptor antagonists in patients suffering from severe low anterior resection syndrome.

Patients and methods

A total of 25 male patients with complaints of uncontrollable urgency or fecal incontinence following sphincter-preserving operations were enrolled in this study. Defecatory status, assessed on the basis of incontinence score (0–20), urgency grade (0–3), and number of toilet visits per day, was evaluated using a questionnaire before and 1 month after the administration of the 5-HT₃ antagonist ramosetron.

Results

All the parameters assessed improved significantly after taking ramosetron for 1 month. The effect was more prominent in cases whose anastomotic line was lower, ie, inside the anal canal. Defecatory function was better in patients who commenced ramosetron therapy within 6 months postoperatively, as compared to those who were not prescribed ramosetron for more than 7 months postoperatively.

Conclusion

These results suggest that 5-HT₃ antagonists are effective for the treatment of low anterior resection syndrome, as in diarrhea-predominant irritable bowel syndrome. The improvement in symptoms is not merely time dependent, but it is related to treatment with 5-HT₃ antagonists.

Neoadjuvant therapy followed by local excision and two-stage total mesorectal excision: a new strategy for sphincter preservation in locally advanced ultra-low rectal cancer

BACKGROUND

With the increased usage of neoadjuvant chemoradiotherapy, improved surgical technique and stapling devices, sphincter-preserving resection has become more frequent for patients with rectal cancer. However, as for locally advanced ultra-low rectal cancer, sphincter-preservation is still facing an enormous challenge.

OBJECTIVE

To introduce an NLT strategy of sphincter-preservation-neoadjuvant therapy (NT) followed by local excision (LE) and two-stage total mesorectal excision (TME)-into the treatment of locally advanced ultra-low rectal cancer (lesions with anal sphincter invasion).

METHODS

From October 2010 to October 2011, nine patients with locally advanced rectal cancer located less than 3 cm from the anal verge were treated by the NLT strategy. All patients had shown good clinical response to NT. The LE procedure was carried transanally 6-8 weeks after completion of the NT. TME was performed to dissect mesorectal lymph nodes 4-6 weeks after LE.

RESULTS

Of the nine patients, the lesion was assessed as T2 in two, T3 in five, and T4 in two before NT, and lymph node metastasis was detected in five patients. The median distance from the tumor to the anal verge was 2.5 cm (range: 1-3 cm). The median follow-up was 27 months (range: 24-34 months). No distant metastasis was detected. Only one patient (11.1%) developed local recurrence at 12 months post-operatively and then underwent abdomino-perineal resection. The remaining eight patients had preserved long-term continence and the median Wexner score at two years post-operation was 4 (range: 2-6).

CONCLUSION

The new NLT strategy can achieve sphincter-preservation in some patients with ultra-low rectal cancer, with favorable oncological outcome and preservation of normal anal sphincter function.

Ultra low resection versus abdomino-perineal excision in low rectal cancer

There have been several important improvements in the management of patients with rectal cancer during the recent 20 years. For more accurate local and distant tumour staging, introduction of neoadjuvant treatments, improved surgery, a more precise macroscopic and microscopic evaluation of the specimen and MDT discussions have all been crucial in improving local control and survival. However, the most important factor has been the TME technique with standardisation of the surgical procedure. For patients with low rectal cancer, the decision making is complex with several treatment options, including the choice between neoadjuvant treatment followed by surgery or surgery alone, restorative procedures or APE. If an APE is necessary, this must also be tailored to the individual patient based on patient's characteristics and the extent of local tumour growth.

Prognostic factors associated with locally recurrent rectal cancer following primary surgery (Review)

Locally recurrent rectal cancer (LRRC) is defined as an intrapelvic recurrence following a primary rectal cancer resection, with or without distal metastasis. The treatment of LRRC remains a clinical challenge. LRRC has been regarded as an incurable disease state leading to a poor quality of life and a limited survival time. However, curative reoperations have proved beneficial for treating LRRC. A complete resection of recurrent tumors (R0 resection) allows the treatment to be curative rather than palliative, which is a milestone in medicine. In LRRC cases, the difficulty of achieving an R0 resection is associated with the post-operative prognosis and is affected by several clinical factors, including the staging of the local recurrence (LR), accompanying symptoms, patterns of tumors and combined therapy. The risk factors following primary surgery that lead to an increased rate of LR are summarized in this study, including the surgical, pathological and therapeutic factors.

Tumor regression grades: can they influence rectal cancer therapy decision tree?

Background. Evaluating impact of tumor regression grade in prognosis of patients with locally advanced rectal cancer (LARC). Materials and Methods. We identified from our colorectal cancer database 168 patients with LARC who received neoadjuvant therapy followed by complete mesorectum excision surgery between 2003 and 2011: 157 received 5-FU-based chemoradiation (CRT) and 11 short course RT. We excluded 29 patients, the remaining 139 were reassessed for disease recurrence and survival; the slides of surgical specimens were reviewed and classified according to Mandard tumor regression grades (TRG). We compared patients with good response (Mandard TRG1 or TRG2) versus patients with bad response (Mandard TRG3, TRG4, or TRG5). Outcomes evaluated were 5-year overall survival (OS), disease-free survival (DFS), local, distant and mixed recurrence. Results. Mean age was 64.2 years, and median followup was 56 months. No statistically significant survival difference was found when comparing patients with Mandard TRG1 versus Mandard TRG2 (p = .77). Mandard good responders (TRG1 + 2) have significantly better OS and DFS than Mandard bad responders (TRG3 + 4 + 5) (OS p = .013; DFS p = .007). Conclusions. Mandard good responders had a favorable prognosis. Tumor response (TRG) to neoadjuvant chemoradiation should be taken into account when defining the optimal adjuvant chemotherapy regimen for patients with LARC.

A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome

The aim of this review is to characterize the functional results and "anterior resection syndrome" (ARS) after sphincter-saving surgery for rectal cancer. The purpose of sphincter-saving operations is to save the anal sphincters by avoiding the need for rectal abdomino-perineal resection with a permanent stoma. A variety of alternative techniques have been proposed and, today, ultra-low anterior resections of the rectum are commonplace. Inevitably rectal resections modify anorectal physiology. The backdrop of the functional asset for ultralow anterior resections is related to a small neorectal capacity with high endo-neorectal pressures that act together on a weakened sphincteric mechanism. Sometimes a defecation disorder called ARS may be induced and the patient experiences an extremely low quality of life. Impaired bowel function is usually provoked either by colonic dysmotility, neorectal reservoir dysfunction, anal sphincter damage or by a combination of these factors. Surgical technique defects can contribute to these possible causes: anastomotic ischemia, short length of the descending colon and stretching of neorectal mesentery may play a role. Unfortunately, there is no therapeutic algorithm or gold standard treatment that may be used for ARS. Nevertheless, it is rational to use conservative therapy first and then resort to surgery. Drugs, rehabilitative treatment and sacral neuromodulation may be used; after failure of conservative methods, surgical treatment can be considered.

Low rectal cancer: classification and standardization of surgery

BACKGROUND

Surgical treatment of low rectal cancer is controversial, and one of the reasons is the lack of definition and standardization of surgery in low rectal cancer.

OBJECTIVE

We classified low rectal cancers in 4 groups with the aim of demonstrating that most patients with low rectal cancer can receive conservative surgery without compromising oncologic outcome.

DESIGN

Patients with low rectal cancer <6 cm from anal verge were defined in 4 groups: type I (supra-anal tumors: >1 cm from anal ring) had coloanal anastomosis, type II (juxta-anal tumors: <1 cm from anal ring) had partial intersphincteric resection, type III (intra-anal tumors: internal anal sphincter invasion) had total intersphincteric resection, and type IV (transanal tumors: external anal sphincter invasion) had abdominoperineal resection. Patients with ultra-low sphincter-preserving surgery (types II-III) were compared with those with conventional sphincter-preserving surgery (type I).

OUTCOME MEASURES

Postoperative mortality, morbidity, surgical margins, local and distant recurrence, and survival were analyzed.

RESULTS

Of 404 patients with low rectal cancer, 135 were type I, 131 type II, 55 type III, and 83 type IV. There was no difference in local recurrence (5% to 9% vs 6%), distant recurrence (23% vs 23%), and disease-free survival (70%-73% vs 68%) at 5 years between ultra-low (types II-III) and conventional (type I) sphincter-preserving surgery. Predictive factors of survival were tumor stage and R1 resection but not the type of tumor or type of surgery.

LIMITATIONS

This study is limited by the retrospective analysis of a database, obtained from a single institution and covering a 16-year period.

CONCLUSION

Classification of low rectal cancers and standardization of surgery permitted sphincter-preserving surgery in 79% of patients with low rectal cancer without compromising oncologic outcome. This new surgical classification should be used to standardize surgery and increase sphincter-preserving surgery in low rectal cancer.

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer

Background

Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR.

Methods

The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score.

Results

The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture.

Conclusions

The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

Management of distal rectal cancer: results from a national survey

Owing to the complexity of distal rectal cancer its management requires a multidisciplinary approach. The diagnosis and the response after neoadjuvant chemoradiotherapy are not easy to assess and therefore the surgical approach is heterogeneous. The purpose of this survey is to evaluate the experiences of members of the Italian Society of Surgery in diagnosis and treatment strategies for rectal cancer and compare it with international practice. A questionnaire was devised comprising 18 questions with 11 sub-items making a total of 29 questions and submitted online to all the 2,500 members of the SIC starting from July 2010. The survey was completed in June 2011. The overall response rate was 17.8 % (444). The majority of the Italian surgeons' responses were in line with the international consensus reflecting the complex management of distal rectal cancer. Other opinions, especially those on staging, diverge from the common view of MRI being the gold standard in the assessment of loco-regional diffusion of the disease and on the superiority of FDG PET-CT versus CT for systemic staging. The timing for the re-staging and for surgery following neoadjuvant chemoradiotherapy does not reflect the international opinion. Italian surgeons are also exposed to the common difficulties encountered internationally in the management of distal rectal cancer. Probably, the implementation of an Italian rectal cancer registry and of many national and international multicentre studies may improve the management of rectal cancer in Italy.

Outcome of surgical resection of second-time locally recurrent rectal cancer

BACKGROUND

Locally recurrent rectal cancer relapses in the pelvis in up to 60 per cent of patients following resection. This study assessed the surgical and oncological outcomes of patients who underwent surgery for re-recurrent rectal cancer.

METHODS

Patients who underwent second-time resection of locally recurrent rectal cancer between 2001 and 2010 were eligible for inclusion. Data were collected on demographics, presentation of disease, preoperative staging imaging, adjuvant therapy, operative detail, histopathology and follow-up status (clinical and imaging) for the primary tumour, and first and second recurrences.

RESULTS

Thirty patients (of 56 discussed at the multidisciplinary meeting) underwent resection of re-recurrent rectal cancer. Postoperative morbidity occurred in nine patients but none died within 30 days. Negative resection margins (R0) were achieved in ten patients, microscopic margin positivity (R1) was evident in 15 and macroscopic involvement (R2) was found in five. Although no patient had distant metastatic disease, 22 had involvement of the pelvic side wall. One- and 3-year overall survival rates were 77 and 27 per cent respectively, with a median overall survival of 23 (range 3-78) months. An R0 resection conferred a survival benefit (median survival 32 (11-78) months versus 19 (6-33) months after R1 and 7 (3-10) months after R2 resection).

CONCLUSION

Surgical resection of re-recurrent rectal cancer had comparable surgical and oncological outcomes to initial recurrences in well selected patients.