Is rectal washout necessary in anterior resection for rectal cancer? A prospective clinical study

Intraluminal washout in rectal and sigmoid colon cancer surgeries with double-stapling technique anastomosis: A single-institution prospective study

Aim

This study aimed to determine the necessity of intraluminal washout through cytological assessment to prevent implantation of exfoliated cancer cells (ECCs) in patients with rectal and sigmoid cancers.

Methods

We studied 140 patients with either sigmoid or rectal cancer who underwent anastomosis surgery using a double-stapling technique. An intraluminal washout sample was collected before and after irrigation with 1000, 1500, or 2000 mL of physiological saline or distilled water. Cytological assessments were conducted using the Papanicolaou classification system, where classes IV and V indicated positive cytological findings.

Results

Initially, 46.4% of the patients (65 out of 140) had positive ECCs. Patients with cancer cells had a significantly shorter distal free margin (DM) from the tumor (p < 0.001). The length of the DM was significantly associated with the tumor distance from the anal verge (p < 0.001). After irrigation with 2000 mL, ECCs were found in only 7.3% of patients. Logistic regression analysis showed that DM (≤50 mm) and tumor size (≥50 mm) were independent risk factors for positive ECCs after intraluminal washout, regardless of the type of irrigation solution used.

Conclusion

In patients with sigmoid colon cancer, adequate preoperative bowel preparation, a long DM, and a small tumor size, a 1000 mL intraluminal washout may be sufficient. By contrast, in patients with rectal cancer with a short DM and a large tumor size, a ≥2000 mL intraluminal washout is required. The different types of irrigation solution did not affect the ECCs. Large randomized controlled trials are required to confirm these results.

Can neoadjuvant chemoradiotherapy affect exfoliated cancer cells in colorectal cancer?

BACKGROUND

To prevent local recurrence caused by exfoliated cancer cells caught in the suture line, intraoperative rectal washout during surgery can be performed to eliminate exfoliated cancer cells. However, the impact of neoadjuvant chemoradiotherapy on exfoliated cancer cells is not well known. This study aimed to identify positive rate of malignant cells in rectal washout fluids of neoadjuvant chemoradiotherapy patients and to determine if neoadjuvant chemoradiotherapy could affect exfoliated cancer cells.

METHODS

A total of 105 patients who underwent rectal washout intraoperatively for distal sigmoid colon and rectal cancer from April 2020 to September 2021 were analyzed. The primary outcome was positive rate of malignant cells in rectal washout fluids of patients who had received neoadjuvant chemoradiotherapy.

RESULTS

The positive rate of malignant cells in washout fluids of patients who had received neoadjuvant chemoradiotherapy was 0.0% and those who had not was 32.1%. The overall positive rate was 23.8%. In the positive group, tumor sizes were bigger (4.64 ± 1.68 cm vs. 3.64 ± 2.00 cm, p = 0.026) and more patients had a fungating tumor shown in preoperative colonoscopy (96.0% vs. 71.3%, p = 0.012). Although these factors did not show statistical significance in multivariable logistic regression analysis, fungating tumor showed a trend towards significance (OR: 7.28, 95% CI: 0.90-58.77, p = 0.063).

CONCLUSIONS

Our study suggests that neoadjuvant chemoradiotherapy could reduce exfoliated cancer cells, and rectal washout for the purpose of eliminating exfoliated cancer cells might be unnecessary in patients who have received neoadjuvant chemoradiotherapy.

Recurrence of sigmoid colon cancer–derived anal metastasis: A case report and review of literature

BACKGROUND

Distant metastasis of colorectal cancer to the anus is very rare, with only 30 related cases published in PubMed thus far. Therefore, recurrence of colorectal cancer derived anus metastases is rarely seen and less presented.

CASE SUMMARY

Here we report an 80-year-old male patient who underwent radical resection for sigmoid colon cancer in January 2010 and another surgery for anal fistula resection in December 2010. Postoperative pathology of the anal fistula revealed a metastatic moderately differentiated adenocarcinoma. The patient subsequently received chemotherapy and radiotherapy. In May 2020, after the patient reported symptoms of anal swelling and pain, computed tomography and magnetic resonance imaging revealed a perianal abscess. Perianal mass biopsy was performed, and the postoperative pathological diagnosis was metastatic moderately differentiated adenocarcinoma.

CONCLUSION

This case highlights that there is a risk of recurrence of anal metastasis of colorectal cancer even after 10 years of follow-up. We also reviewed the literature and discuss potential mechanisms for anal metastasis of colorectal cancer, thus providing some suggestions for treatment of these cases.

Effect of rectal washout on local recurrence of rectal cancer in the era of total mesorectal excision: Meta-analysis

INTRODUCTION

Presence of intraluminal viable cancer cells implanting into the anastomosis has been proposed as a potential cause for developing local recurrence in patients undergoing anterior resection for rectal cancer. Rectal washout has been proposed as a method to prevent this from happening. There have been conflicting reports in literature regarding the effect of rectal washout on local recurrence. We aim to look at the role of rectal washout in preventing local recurrence of rectal cancer in patients undergoing total or tumor-specific mesorectal excision (TME).

MATERIALS AND METHODS

A literature review of studies evaluating the role of rectal washout on rectal cancer local recurrence was performed using PubMed, Scopus, EMBASE and non-English language literature search using CiNii (Japanese) and CNKI (Chinese). Inclusion criteria were use of TME, comparison of rectal washout with no washout, and evaluation of local recurrence as outcome.

RESULTS

Four studies were identified according to inclusion criteria. The meta-analysis showed a protective effect of rectal washout on local recurrence (OR 0.45 95% CI 0.45-0.75). However, one of the studies included had more than 90% weightage. Excluding this study from analysis showed no difference on local recurrence with rectal washout (OR 0.94, 95% CI 0.37-2.36).

CONCLUSION

The effect of rectal washout on rectal cancer local recurrence in patients who undergo TME is questionable and needs to be evaluated further by prospective studies.

Is Intraluminal Washout Necessary for Patients with Sigmoid Colon Cancer to Eliminate Exfoliated Cancer Cells as in Patients with Rectal Cancer? A Pilot Study at a Single Institute

Objectives:

Rectal stump washout has been widely performed to prevent the implantation of exfoliated cancer cells (ECCs) in patients with rectal cancer. However, it remains unclear whether intraluminal washout before transection is required in patients with sigmoid colon cancer. Therefore, this pilot study was conducted to elucidate the necessity of intraluminal washout for sigmoid colon cancer patients in comparison with rectal cancer patients by cytological assessments.

Methods:

A total of 16 patients with sigmoid colon cancer and 24 patients with rectal cancer who underwent sigmoidectomy or anterior resection with anastomosis using double-stapling technique were enrolled. A transanal washout sample was collected before washout and after irrigation with 500 and 1,000 mL of saline. Cytological assessments were conducted according to the Papanicolaou classification, and class IV and V cells were defined as malignant.

Results:

Before washout, exfoliated cancer cells were found in 15 of 24 (62.5%) patients with rectal cancer and in 1 of 16 (6.2%) patients with sigmoid colon cancer (p < 0.001). Distal-free margin from the tumor was significantly shorter in patients with cancer cells (p = 0.002), and the length of the distal-free margin was significantly associated with the tumor location. After irrigation with 500 and 1,000 mL of saline, no cancer cell was found in all patients with sigmoid colon cancer, whereas ECCs were still found in five patients with rectal cancer (20.8%).

Conclusions:

Intraluminal washout with 1,000 mL may be sufficient for sigmoid colon cancer patients with longer distal-free margin. A large-scale, randomized controlled study is necessary to confirm these results.

The effect of rectal washout on local recurrence following rectal cancer surgery

Introduction Local recurrence after surgery for rectal cancer is associated with significant morbidity and debilitating symptoms. Intraoperative rectal washout has been linked to a reduction in local recurrence but there is no conclusive evidence. The aim of this study was to evaluate whether performing rectal washout had any effect on the incidence of local recurrence in patients undergoing anterior resection for rectal cancer in the context of the current surgical management. Methods A total of 395 consecutive patients who underwent anterior resection with or without rectal washout for rectal cancer between January 2003 and July 2009 at a high volume single institution were analysed retrospectively. A standardised process for performing washout was used and all patients had standardised surgery in the form of total mesorectal excision. Neoadjuvant and adjuvant therapy was used on a selected basis. Patients were followed up for five years and local recurrence rates were compared in the two groups. Results Of the 395 patients, 297 had rectal washout and 98 did not. Both groups were well matched with regard to various important clinical, operative and histopathological characteristics. Overall, the local recurrence rate was 5.3%. There was no significant difference in the incidence of local recurrence between the washout group (5.7%) and the no washout group (4.1%). Conclusions Among our cohort of patients, there was no statistical difference in the incidence of local recurrence after anterior resection with or without rectal washout. This suggests that other factors are more significant in the development of local recurrence.

The importance of rectal washout for the oncological outcome after Hartmann's procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry

BACKGROUND

During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer.

METHODS

A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed.

RESULTS

A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival.

CONCLUSIONS

The oncological outcome did not improve when washout was performed in HP for rectal cancer.

Anastomotic recurrence of colon cancer: Genetic analysis challenges the widely held theories of cancerous cells' intraluminal implantation and metachronous carcinogenesis

BACKGROUND AND OBJECTIVES

Anastomotic recurrence (AR), whose etiopathogenesis is attributed to intraluminal implantation of cancerous cells or metachronous carcinogenesis, is a major issue for patients undergoing colon cancer (CC) resection. The objective of the study is to throw some light on AR etiopathogenesis and to identify risk factors of AR in selecting patients to undergo early endoscopy.

METHODS

An analysis of clinical and histopathological parameters, including MSI and LOH of seven sites (Myc-L, BAT26, BAT40, D5S346, D18S452, D18S64, D16S402) was performed in primary CC and AR of 18 patients. They were then compared to 36 controls not developing AR.

RESULTS

A genetic instability was present in 16/18 patients, with distinct genetic patterns between primaries and ARs. LOH at 5q21 and/or 18p11.23 were found in both primary and AR in >50% of cases, but this rate was no different from control population. CEA resulted as associated with AR (P = 0.03), whereas N status presented a borderline result (P = 0.08).

CONCLUSIONS

Our findings challenge present theories about AR development. No "genetic marker" has been found. CEA and, to a lesser extent, N status, appear associated with AR. Rectal washout is seemingly meaningless. Iterative resection should be recommended since a long survival may be expected. J. Surg. Oncol. 2016;114:228-236. © 2016 Wiley Periodicals, Inc.

Benefit of rectal washout for anterior resection and left sided resections

PURPOSE

To assess the effectiveness of rectal wash out in preventing local recurrence for patients who undergo anterior resection for recto-sigmoid cancer.

MATERIALS AND METHODS

A best evidence topic was constructed according to a structured protocol. Medline 1948-2015 and EMBASE 1980 to 2015 using the OVID interface: ( Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched.

OUTCOMES

Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 meta-analyses.

CONCLUSIONS

On the basis of current evidence, rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to address this issue would formally answer this question.

Reasonable application of rectal washout in surgery for rectal cancer: Influence on prognosis and recurrence

The growth of residual tumor cells may cause postoperative colorectal anastomotic recurrence, which mainly exists in the intestine; however, rectal washout can significantly reduce the number of free tumor cells in the intestinal cavity and decrease the local recurrence rate. Clinical application of rectal washout has been tried in operation, but the effect remains controversial. This paper mainly introduces the method of rectal washout, washout fluid type, amount of washout fluid, relation of rectal washout with local recurrence, with emphasis on the influence of reasonable application of rectal washout on prognosis and recurrence of rectal cancer after surgery.

Intra-operative rectal washout with saline solution can effectively prevent anastomotic recurrence: a meta-analysis

BACKGROUND AND OBJECTIVE

Rectal washout with saline solution may theoretically prevent anastomotic recurrence in patients with resectable rectal cancer, although exact clinical effects have not yet been determined. In order to derive a more precise estimation of the relationship, the present meta-analysis was performed.

METHOD

Relevant studies were identified by a search of Medline, Embase and Google Website with no restrictions to September 1, 2013, and included in the systematic review and meta-analysis.

RESULTS

5 trials (642 participants) were included to assess the association between rectal washout with saline solution and anastomotic recurrence. The rate of anastomotic recurrence (AR) was 6.23% (40/642), with the pooled OR derived from the five studies being 0.32 (95 % CI=0.15-0.70, P=0.004). The pooled OR derived from the TME and radical resection subgroups were 0.72 (95%CI=0.16-3.12, P=0.66) and 0.51 (95%CI=0.13-1.96, P=0.32), respectively.

CONCLUSION

Results from this analysis show that intra-operative rectal washout with mere saline solution largely reduces the risk of anastomotic recurrences in patients with resectable rectal cancer.

Association between irrigation fluids, washout volumes and risk of local recurrence of anterior resection for rectal cancer: a meta-analysis of 427 cases and 492 controls

BACKGROUND

Rectal washout can prevent local recurrence after anterior resection of rectal cancer. Few studies have focused particularly on the association between irrigation fluids volume or agents and the risk of local recurrence after anterior resection of rectal cancer.

OBJECTIVE

To estimate the association between irrigation fluids types, volumes of rectal washout and risk of local recurrence after anterior resection for cancer.

DATA SOURCES

Relevant studies were identified by a search of Medline, Embase, Wiley Online Library, China National Knowledge Infrastructure, Cochrane Oral Health Group Specialized Register, Wanfang databases and Google Website from their inception until October 18,2013.

STUDY SELECTION

Studies reporting the association between rectal washout types and volumes and risk of local recurrence after anterior resection for cancer were included.

INTERVENTIONS

Eligible studies used rectal washout. Control groups were defined as no washout.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects model were used to obtain summary estimates of RR and 95% CI, with Stata version 11 and RevMan 5.2.5 softwares used. The quality of report was appraised in reference to the MINORS item.

RESULTS

Of the 919 rectal cancer patients in 8 included studies, a total of 61(6.64%) cases of local recurrence were reported, with a pooled RR 0.51 (95%CI = 0.28-0.92, P = 0.03). The RRs 0.37 and 0.39 in normal saline and washout volume (≥ 1500 ml normal saline) subgroup, respectively, indicated that rectal washout with normal saline, or ≥ 1500 ml in volume could significantly reduce local recurrence (LR) rate (95% CI = 0.17-0.79, P = 0.01; 95% CI = 0.18-0.87, P = 0.02) after anterior resection for cancer.

LIMITATION

The included studies were non-randomized observational studies, with diversity of study designs.

CONCLUSION

Rectal washout with normal saline alone can reduce the risk of local recurrence in patients with resectable rectal cancer, and 1.5 liters rectal washout in volume is recommended.

Association between irrigation fluids, washout volumes and risk of local recurrence of anterior resection for rectal cancer: a meta-analysis of 427 cases and 492 controls

BACKGROUND

Rectal washout can prevent local recurrence after anterior resection of rectal cancer. Few studies have focused particularly on the association between irrigation fluids volume or agents and the risk of local recurrence after anterior resection of rectal cancer.

OBJECTIVE

To estimate the association between irrigation fluids types, volumes of rectal washout and risk of local recurrence after anterior resection for cancer.

DATA SOURCES

Relevant studies were identified by a search of Medline, Embase, Wiley Online Library, China National Knowledge Infrastructure, Cochrane Oral Health Group Specialized Register, Wanfang databases and Google Website from their inception until October 18,2013.

STUDY SELECTION

Studies reporting the association between rectal washout types and volumes and risk of local recurrence after anterior resection for cancer were included.

INTERVENTIONS

Eligible studies used rectal washout. Control groups were defined as no washout.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects model were used to obtain summary estimates of RR and 95% CI, with Stata version 11 and RevMan 5.2.5 softwares used. The quality of report was appraised in reference to the MINORS item.

RESULTS

Of the 919 rectal cancer patients in 8 included studies, a total of 61(6.64%) cases of local recurrence were reported, with a pooled RR 0.51 (95%CI = 0.28-0.92, P = 0.03). The RRs 0.37 and 0.39 in normal saline and washout volume (≥ 1500 ml normal saline) subgroup, respectively, indicated that rectal washout with normal saline, or ≥ 1500 ml in volume could significantly reduce local recurrence (LR) rate (95% CI = 0.17-0.79, P = 0.01; 95% CI = 0.18-0.87, P = 0.02) after anterior resection for cancer.

LIMITATION

The included studies were non-randomized observational studies, with diversity of study designs.

CONCLUSION

Rectal washout with normal saline alone can reduce the risk of local recurrence in patients with resectable rectal cancer, and 1.5 liters rectal washout in volume is recommended.

Systematic review and meta-analysis of rectal washout on risk of local recurrence for cancer

BACKGROUND

It has been shown that intraluminal washout (WO) can prevent local recurrence (LR) of rectal cancer. This meta-analysis was to evaluate the association of rectal WO and the risk of LR after anterior resection in patients with rectal cancer.

METHODS

The relevant studies were identified by a search of the MEDLINE, Embase, Wiley Online Library, and Cochrane Oral Health Group Specialized Register with no restrictions on October 18, 2013, and these studies were included in a systematic review and meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in fixed effects model.

RESULTS

A total of nine studies were included in our study, yielding a total of 5519 patients, and pooled ORs for overall LR in corresponding subgroups were calculated. Rectal WO was associated with a lower risk for LR (240/4176, 5.75% versus 9.75%, 131/1343, OR = 0.53, 95% CI = 0.42-0.68, and P < 0.00001) in patients with anterior resection, having total mesorectal excisions (234/3942, 5.93% versus 9.34%, 97/1039, OR = 0.59, 95% CI = 0.46-0.75, and P < 0.00001), and after radical resection (RR; 122/2665, 4.99% versus 8.90%, 74/831, OR = 0.56, 95% CI = 0.41-0.78, and P = 0.0005), with an overall LR rate of 6.72% (371/5519). But, the stability of RRs is not high in the total mesorectal excisions or RR subgroup by sensitivity analysis.

CONCLUSIONS

The use of rectal WO decreases risks of LR in patients after anterior resection of cancer.

Intraoperative rectal washout in rectal cancer surgery: a survey of current practice in the UK

OBJECTIVES

Due to concerns about implantation of malignant cells during surgery for rectal cancer, traditionally, intraoperative rectal washout (IORW) has been performed to prevent local recurrence. But with the advent of laparoscopic surgery, many surgeons have abandoned this practice. The aim of this study was to assess current practice among colorectal surgeons in the UK.

METHODS

A 10-item questionnaire was sent by email to 452 consultant surgeons, who were members of the Association of Coloproctology of Great Britain & Ireland, and had previously agreed to participate in research projects.

RESULTS

The mean age of the 149 responders (n = 149, 33.0%) was 49.2 years. The mean number of years in independent practice was 12.1, and the mean number of rectal cancer cases performed per year was 20.3 and 20.6, in the years 2010 and 2011 respectively. 74.3% of the responders believed that there is an advantage in performing IORWs in rectal cancer resections. Of the 71.8% of all responders who performed laparoscopic rectal cancer resections, 54.8% routinely performed IORWs during laparoscopic resections. However, 87.2% of all responders performed IORWs in open resections for rectal cancer, and 79.2% had routinely performed IORWs before the advent of laparoscopic rectal cancer surgery.

CONCLUSIONS

Most colorectal surgeons believe that there is an advantage in performing IORWs. Although, most surgeons would routinely perform IORWs in open resections, they do not routinely perform these in laparoscopic resections.

Evaluation of the presence of intraluminal cancer cells following rectal washout in rectal cancer surgery

BACKGROUND

The presence of intraluminal tumour cells in colorectal cancer is known, as is their ability to implant in colorectal anastomoses, causing perianastomotic tumour growth. There is no consensus as to the volume and agent to use for rectal washout. The purpose of this study was to assess the efficacy of our current routine for rectal washout in eliminating intraluminal tumour cells.

METHODS

Sixty consecutive patients undergoing low anterior resection or low Hartmann's procedure for rectal cancer at our unit were included. After the pelvic dissection was completed, the bowel was cross-clamped distal to the tumour and the prewashout sample (no. 1), was obtained by instilling 50 ml of saline and collecting the return fluid. A rectal washout followed using 500 ml of sterile water, 2 × 500 ml of 70 % ethanol and 500 ml of sterile water (sample no. 2-4) and the postwashout sample (no. 5) was obtained by using 50 ml of saline. The samples were examined and categorized as non-malignant or malignant at the Department of Pathology. The usual pathology report information was also assessed.

RESULTS

In 33 of the 60 patients, cancer cells were identified in the prewashout sample. The rectal washout eliminated intraluminal cancer cells in 30 of the 33 patients. All of the remaining 3 had a higher blood loss (p = 0.026) and a tendency towards more polypoidal tumours (p = 0.053).

CONCLUSIONS

A rectal washout volume larger than 2,000 ml might be necessary to eliminate all intraluminal tumour cells in total mesorectal excision for rectal cancer.

The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis

BACKGROUND

Implantation of exfoliated cancer cells has been suggested as a possible mechanism of local recurrence at the site of colorectal anastomosis. Intraoperative rectal washout has been suggested to eliminate free cancer cells; however, there is no conclusive evidence of a beneficial effect of intraoperative rectal washout on local recurrence after anterior resection of rectal cancer.

METHODS

Studies published through February 2012 evaluating the impact of intraoperative rectal washout for local recurrence or positive cytology from donuts wash were identified by an electronic literature search. A meta-analysis was performed using the DerSimonian-Laird random-effects models to compute risk ratio (RR) along with 95% confidence intervals (CI).

RESULTS

Nine studies met the inclusion criteria, yielding a total of 5,395 patients. Eight studies evaluated overall local recurrence, including anastomotic recurrence, and five of the eight studies evaluated anastomotic recurrence separately. Two studies evaluated positive cytology from donuts wash. Local recurrence rate was 5.79% in the washout group and 10.05% in the no washout group-a difference that was statistically significant (RR = 0.57; 95% CI = 0.46-0.71; P < 0.00001). Rectal washout significantly reduced the risk of anastomotic recurrence (RR = 0.3; 95% CI = 0.12-0.71; P = 0.007). No influence of rectal washout was observed on positive cytology from donuts wash.

CONCLUSIONS

From the results of this meta-analysis, it may be justified to recommend intraoperative rectal washout to prevent local recurrence in rectal cancer surgery.

Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis

AIM

The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer.

METHOD

The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE.

RESULTS

Five nonrandomized studies including a total of 5012 patients were identified. Meta-analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43-0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39-0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42-0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39-0.98).

CONCLUSION

Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.

Superiority of laparoscopic rectal surgery: Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade, laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field, the lack of precise anatomy of the pelvis, immature procedures of rectal transaction and so on. On the other hand, maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness. However, some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes. This review article discusses how to keep a clear operative field, removing normally existing abdominal structures, and how to transact the rectum and restore the discontinuity based on anatomical investigations. According to this review, laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far, actually entering a new era.

Transanal division of the anorectal junction followed by laparoscopic low anterior resection and coloanal pouch anastomosis: A technique facilitated by a balloon port

We performed a laparoscopic ultra low anterior resection in two patients with low rectal cancers (3 cm from dentate line). A transanal division and continuous suture closure of anorectal junction was performed first followed by laparoscopic low anterior resection. A handsewn anastomosis between colonic pouch/transverse coloplasty and anal canal was facilitated by use of a transanal balloon port.

Totally laparoscopic sigmoid colectomy with transanal specimen extraction

BACKGROUND

Conventional techniques for laparoscopic-assisted colectomy (LAC) require abdominal minilaparotomy for extraction of the specimen. Abdominal wound complications often increase the invasiveness of LAC. To decrease the incidence of wound complications, natural orifice specimen extraction (NOSE) has been reported. However, only a few devices that allow smooth extraction and reduced intracorporeal contamination have been reported previously. We performed totally laparoscopic sigmoid colectomy using transanal specimen extraction (TASE) and the Alexis(®) wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA). We document this simple and safe technique and its short-term results.

METHODS

We prospectively collected data on 18 patients who underwent totally laparoscopic sigmoid colectomy with TASE from April 2009 to July 2010. Lymph node dissection and transection of proximal and distal colon were performed in conventional manner. The transected rectal stump was opened transversely, and a long Babcock grasper was inserted transanally through the opened rectal stump. One of a pair of Alexis rings was held and pulled out of the anus. The other ring was placed in the opened rectal stump. The specimen was then extracted transanally through the Alexis. After the Alexis had been removed, the rectal opening was reclosed with a linear stapler. End-to-end colorectal anastomosis was then performed using the double-stapling technique.

RESULTS

Transanal extraction was achieved in 17 cases. We switched to conventional LAC in a case involving a bulky specimen. In 16 cases not including the combined cholecystectomy case, mean operation time was 241 min. One case was complicated by anastomotic leakage and wound infection, while another had enterocolitis. Median hospital stay was 6 days. All patients remained disease free. Mean Wexner score at 12 months after operation was 2.3.

CONCLUSION

Totally laparoscopic sigmoid colectomy using TASE and the Alexis appears to be feasible, safe, and oncologically acceptable for selected cases.

Rectal washout and local recurrence of cancer after anterior resection

BACKGROUND

Adenocarcinomas of the rectum shed viable cells, which have the ability to implant. Intraoperative rectal washout decreases the amount and viability of these cells, but there is no conclusive evidence of the effect of rectal washout on local recurrence after rectal cancer surgery.

METHODS

Data were analysed from a population-based registry of patients who had anterior resection from 1995 to 2002 and were followed for 5 years. Rectal washout was performed at the discretion of the surgeon. National inclusion of patients with rectal cancer and follow-up was near complete (approximately 97 and 98 per cent respectively).

RESULTS

A total of 4677 patients were analysed (3749 who had washout, 851 no washout and 77 with information missing); 52.0 per cent of patients in the washout group and 41.4 per cent in the no-washout group had preoperative radiotherapy (P < 0.001). Local recurrence rates were 6.0 and 10.2 per cent respectively (P < 0.001). Univariable and multivariable logistic regression analyses produced odds ratios that favoured washout: 0.56 (95 per cent confidence interval (c.i.) 0.43 to 0.72) and 0.61 (0.46 to 0.80) respectively (both P < 0.001). In multivariable analysis restricted to patients who had curative surgery, the odds ratio was 0.59 (95 per cent c.i. 0.44 to 0.78; P < 0.001).

CONCLUSION

There was a more favourable outcome in patients after rectal washout than without.

Clinicopathological features of anastomotic recurrence after an anterior resection for rectal cancer

PURPOSE

Anastomotic recurrence after an anterior resection for rectal cancer has not been analyzed in detail in the era of total mesorectal excision. This study tried to clarify the characteristics of patients with anastomotic recurrence when compared to the pelvic recurrence.

METHODS

This study compared the clinicopathological data of 21 isolated recurrent patients that were treated between 1998 and 2007, including eight with anastomotic recurrence and 13 with pelvic recurrence.

RESULTS

The rate of positive serum carcinoembryonic antigen level at the time of recurrence is 0% in the anastomotic recurrence group and 85% in the pelvic recurrence group (p < 0.001). The clinical symptoms presented in 13% in the anastomotic recurrence group, in comparison to 69% in the pelvic recurrence group (p = 0.024). The median time from the initial resection until recurrence was 14 months in the anastomotic recurrence group, whereas it was 12 months in the pelvic recurrence group (p = 0.992). The survival rate of patients with anastomotic recurrence was higher than those with pelvic recurrence (p = 0.005).

CONCLUSION

A difference was observed in the serum carcinoembryonic antigen, clinical symptom, and survival between patients with anastomotic and pelvic recurrence. Furthermore, according to these results, we should pay attention to these clinical features in the follow-up period.

Is rectal washout effective for preventing localized recurrence after anterior resection for rectal cancer?

PURPOSE

The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer.

METHODS

A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed.

RESULTS

Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2-2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37-3.92).

CONCLUSIONS

Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue.

Suture-line recurrence at a jejunojejunal anastomosis after gastrectomy for gastric cancer

Local recurrence at a gastrojejunal anastomosis is common in patients after gastrectomy for gastric carcinoma, but recurrence at a jejunojejunal anastomosis without recurrence at a gastrojejunal anastomosis is extremely rare. We report a case of suture-line recurrence at a jejunojejunal anastomosis without recurrence at the gastrojejunal anastomosis or in the remnant stomach in a patient 23 months after receiving a Billroth II gastrectomy for gastric cancer. We attributed the implantation of cancer cells at the jejunojejunal anastomosis to contamination of the stapler with cancer cells exfoliated in the gastric mucus during the construction of the gastrojejunal anastomosis. We therefore consider that different surgical instruments, such as automatic anastomotic devices and automatic suturing devices, must be used in each phase of the surgical procedure for gastric cancer.

Benefits of povidone-iodine solution in colorectal operations: science or legend

Povidone-iodine solution (Betadine) has long been accepted as an effective topical broad spectrum antiseptic, disinfectant, and tumoricidal agent. In colorectal operations, this solution generally has been used for the purpose of minimizing postoperative septic complications and reducing cancer recurrence, although the optimal application, advantages, and undesirable side effects have been debated. With limited prospective, randomized, controlled trials and insufficient data available, this article examines the safe and effective clinical applications of this solution for colorectal operations.

Recurrence of gastric cancer in the jejunal pouch after completion gastrectomy

We herein present a case of recurrence of gastric cancer in the jejunal pouch after total gastrectomy in a 74-year-old man. He had a history of two operations for gastric cancer. The second operation was a completion gastrectomy with jejunal pouch reconstruction and regional lymphadenectomy, for gastric cancer in the cardia of the remnant stomach, performed 2 years and 9 months before the present admission. A follow-up endoscopy showed three elevated tumors along the suture lines in the jejunal pouch in the upper digestive tract. Resection of the jejunal pouch was performed. Gross pathological examination revealed elevated lesions along the staple suture lines in the jejunal pouch. Histopathologically, moderately differentiated tubular adenocarcinoma involving the muscular layer, without lymphatic metastases, was recognized. Recurrence of gastric cancer in the jejunal pouch after resection is rare. We suggest that implantation of exfoliated cancer cells gave rise to the recurrence of tumors on the suture line in this patient. We also review two cases of gastric cancer in the jejunal pouch after resection previously described in the literature.

A rare case of repeated anastomotic recurrence due to tumor implantation after curative surgery for sigmoid colon cancer

Background

Anastomotic recurrence is often experienced at colocolic or colorectal anastomoses. Tumor cell implantation has been reported as the mechanism of anastomotic recurrence. However, anastomotic recurrence occurring repeatedly after curative surgery is rare. We herein report a rare case of repeated anastomotic recurrence after curative surgery for sigmoid colon cancer.

Case presentation

A 51-year-old man underwent radical surgery for sigmoid colon cancer. However, anastomotic recurrence developed three times during three years and six months after the initial operation in spite of irrigation with 5% povidone-iodine before anastomosis. The serum carcinoembryonic antigen (CEA) level had been within normal limits after sigmoidectomy. Finally, the patient underwent abdominoperineal resection. The clinico-pathological findings revealed that possible tumor cell implantation caused these anastomotic recurrences. The patients survived without recurrence during the follow-up period of seven years and nine months.

Conclusion

We experienced a rare case of repeated anastomotic recurrence due to possible tumor implantation after curative surgery for sigmoid colon cancer; however the prognosis was ultimately very good. CEA monitoring was insensitive for detection of anastomotic recurrence in this case.