Management of large encircling mid-rectal adenomas in frail patients

Revisiting the Trans-Sacral Approach for Large Rectal Adenomas, Surgical Technique, and Oncological Outcome: a Case Series

The standard oncologic surgeries for rectal carcinoma are radical trans abdominal procedures, However, these radical procedures are not suitable for large rectal adenomas. The transsacral approach for rectal adenoma was first described by Kraske and since then it has been utilized for various benign conditions of low and mid-rectum as well as for certain cancers. We are presenting a series of 5 consecutive cases of trans-sacral resection done in the past 7 years between January, 2016, until June, 2023, at the Department of Surgical Oncology, Cancer Research Institute, HIMS Dehradun, for large mid- and lower rectal adenoma. There were 5 patients who underwent transsacral excision of rectal adenoma. Three patients were male and 2 were female. All the patients underwent surgery after confirming the diagnosis of adenoma and metastatic work up. The postoperative histopathological examination showed adenocarcinoma infiltrating submucosa (T1) in one patient; however, other 4 patients had adenoma reconfirmed. The transsacral approach may not be the method of choice for the rectal carcinoma but it is a very useful surgical alternative to the large rectal adenoma where there is no invasive component and which cannot be managed by any other methods.

Successful Resection of a Large Rectal Adenoma Using the Transsacral Approach

The transsacral approach is not routinely used for treating rectal tumors. We report the case of a 65-year-old man with a large adenoma at the posterior wall of the mid-rectum who was treated via the transsacral approach. The same lesion had been treated using transsacral endoscopic microsurgery 8 years previously. Moreover, 11 years previously he had undergone a laparotomy for bladder cancer, and an Indiana pouch had been constructed. Abdominal computed tomography showed that the pouch was adjacent to the rectum. Therefore, the less-invasive transsacral approach, rather than the transabdominal approach, was chosen for treatment. The lesion was successfully resected, without disturbing the pouch. Histological analysis indicated tubular adenoma, with a small focus of intramucosal adenocarcinoma, and negative margins. Thus, we achieved successful resection of mid-rectal lesions via the transsacral approach, without the morbidity associated with major laparotomy. We suggest that this procedure should be a part of a surgeon's armamentarium.

The Kraske procedure: a critical analysis of a surgical approach for mid-rectal lesions

BACKGROUND AND OBJECTIVES

To analyze the Kraske procedure as an approach to mid-rectal disease.

METHODS

Twenty-two patients underwent a Kraske procedure at either Duke University Medical Center, the Durham Veterans Administration Medical Center, or the Durham Regional Hospital between 1992 and 1997. The clinical and pathologic characteristics of these patients were retrospectively analyzed and compared with previous published series.

RESULTS

Of the 22 patients, 13 underwent resection of an adenocarcinoma and 9 underwent resection of a villous adenoma. Post-operative complications included four fecal fistulas (two of which required a temporary diverting colostomy), two wound infections, two cases of urinary retention, and one case of transient fecal incontinence.

CONCLUSIONS

The Kraske procedure minimizes exposure of mid-rectal lesions without the morbidity of a major laparotomy. However, it does carry a moderate complication rate and thus should be utilized selectively in managing patients with mid-rectal tumors not amenable to other treatment options.

Dorsal transsacrococcygeal rectal approach

A modification of the dorsal rectal approach is described as an alternative to consider in selected low and middle rectal lesions unsuitable for the transanal approach. The dorsal rectal approach is performed through the sacrococcygeal joint and below the gluteus maximus muscle resulting in an easier, safe, and well-tolerated procedure.

Complications are Increased with the Need for an Abdominal-Assisted Kraske Procedure

The Kraske procedure offers a sphincter-saving alternative for surgical correction of rectal disease. This study was performed to investigate the complication rate with the traditional (transsacral) Kraske procedure versus an abdominal-assisted Kraske approach (laparoscopic or open). We conducted a retrospective review of all patients undergoing the Kraske procedure at Harper University Hospital over a 10-year period. A total of 54 patients were identified. Indications for surgery included rectal carcinoma (43), large villous adenomas (6), and other (5). Average postoperative follow-up was 40 ± 25 months (mean ± SD). Complications included rectocutaneous fistulae (9), perineal infections (13), and incontinence (8). In patients requiring an abdominal-assisted approach for colorectal mobilization, the fistula rate was significantly higher (33% vs 3%; P = 0.007), as were the rates of perineal infections (33% vs 17%) and of initial incontinence (25% vs 7%). The laparoscopic-assisted approach significantly reduced the operating time (272 ± 72 minutes) compared to the open-assisted approach (498 ± 138 minutes) ( P < 0.001). The traditional Kraske procedure can be utilized in a safe, effective manner for treatment of rectal disease. Knowledge of the increased rate of complications with the abdominal-assisted Kraske approach can guide the patient and physician considering sphincter salvage.

Radical trachelectomy via a trans-sacral approach: a case report

BACKGROUND

Endometrial cancer may arise in patients previously treated for rectal cancer. Surgical management can be challenging, and the gynecologic oncologist may need to employ alternative surgical approaches.

CASE

A 71-year-old female with a history of Dukes class B rectal cancer previously treated by abdominoperineal resection and pelvic radiation therapy subsequently developed an endometrial cancer. Initial surgical management was difficult, and the entire cervix could not be removed. The patient recurred locally the following year and was managed by radical trachelectomy via a trans-sacral approach.

CONCLUSION

Locally recurrent endometrial cancer can pose difficult management decisions. Radical resection may be the only alternative. Unusual situations may require adaptation of different surgical approaches of which the gynecologic oncologist must be aware.

Local therapy for rectal cancer

Local procedures for carefully selected distal rectal cancer offer significant advantages such as sphincter preservation and avoidance of radical surgery. However, since preoperative selection criteria including current imaging modalities are unable to definitively stage regional lymph node status, local therapies for rectal cancer have the inherent potential disadvantage of undertreating a fraction of patients due to unresected mesorectal/regional lymph node disease. Current available data suggests that the local approach may be appropriate only for carefully selected T1 tumors with favorable pathologic features. Inferior local control and survival reported for T2 tumors and T1 tumors with unfavorable features, despite the addition of chemoradiation, outweigh the advantages of the local approach. Patients with unfavorable tumors who are unable to tolerate radical resection or who refuse surgery may be treated with local excision with or without adjuvant chemoradiation. Other modalities, such as electrocoagulation and endocavitary radiation, may also be valuable in this setting, as well as preoperative chemoradiation followed by local excision. Regardless of the approach used, all patients undergoing local therapy of a rectal cancer require careful long-term follow-up, because these patients remain at significant risk for local recurrence and distant failure.