The abdominoperineal resection itself is associated with an adverse outcome: The European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer

Prognosis and quality of life in patients with locally advanced rectal cancer after abdominoperineal resection in the CAO/ARO/AIO-04 randomized phase 3 trial

Low anterior resection (LAR) and abdominoperineal resection (APR) are the two main surgical procedures after preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer. APR is associated with poorer prognosis; however existing data do not consider intensified CRT (5-Fluorouracil (5-FU)/Oxaliplatin + radiation) protocols. Clinicopathological data of patients treated with APR and LAR from the CAO/ARO/AIO-04 trial were analysed in terms of prognostic parameters and quality of life (QoL). Based on higher response rate after intensified CRT, subgroup analyses were performed. Data from n = 1173 patients were assessed. APR after preoperative CRT was associated with a significantly worse overall survival (p = 0.0056), disease-free survival (p < 0.0001) and local recurrence rate (p = 0.0047). Clinicopathological data including clinical T stage (p < 0.000001), grading (p = 0.0038), postoperative lymph node (LN) positivity (p = 0.013), and number of positive LN (p = 0.0049) significantly differed between procedures and showed higher values in APR patients. The quality of total mesorectal excision (TME) was significantly better (p < 0.0001) and complete resection rates were higher (p = 0.0022) in LAR compared to APR patients. Subgroup analyses showed worse LR rates in APR patients after standard CRT (5-FU mono and radiation) but not after intensified CRT. After 3 years, role functioning (p = 0.019) and physical functioning (p = 0.001) had a slightly poorer outcome in APR patients. The poorer prognosis of patients undergoing APR for locally advanced rectal cancer may be explained by clinicopathological characteristics. Intensified CRT may compensate for the higher risk of LR after APR in patients with worse TME quality. QoL in APR patients was comparable to LAR patients.

Risk factors for local recurrence of rectal cancer after curative surgery: A single-center retrospective study

PURPOSE

Approximately 7% of patients with rectal cancer experience local recurrence within 5 years of curative surgery. A positive circumferential resection margin (CRM) is among the most significant risk factors. Other reported risk factors include histopathologic type, anastomotic leakage, positive distal margins, and more recently, the anterior localization of the tumor. In this retrospective cohort study, we aimed to assess risk factors for local recurrence in our institution, with a focus on tumor localization as an independent negative predictive factor.

PATIENTS AND METHODS

From 2007 to 2018, all patients with stage II or III rectal cancer were included in this study. Patients underwent neoadjuvant chemoradiotherapy followed by surgical resection with total mesorectal excision. The tumor's anterior or posterior localization was assessed by preoperative endosonography or magnetic resonance imaging. Risk factors for local recurrence were assessed using univariate and multivariate regression analyses.

RESULTS

A total of 128 patients were included. The 3-year and 5-year local recurrence rates were 4.7% and 7%, respectively. In univariate and multivariate analyses, the histologic type of a poorly differentiated tumor (P=0.001) and a positive CRM (P=0.001) were correlated with local recurrence. Tumor localization (anterior or posterior) was not identified as a statistically significant factor associated with local recurrence.

CONCLUSION

Positive CRM and a poorly differentiated tumor histological subtype were found to be independent risk factors for local recurrence. In contrast to previous findings, anterior localization was not identified as an independent risk factor for local recurrence in our patient cohort.

Contemporary practices in abdominoperineal resection for early-stage rectal cancer in the United States

AIM

In contrast to significant advances in organ preservation in locally advanced rectal cancer, the contemporary management of early-stage rectal cancer, including the frequency of abdominoperineal resections, remains largely unexplored in the United States. Therefore, we assessed the utilization of neoadjuvant therapy and oncological resections in early-stage rectal cancer patients.

STUDY DESIGN

This is a retrospective cohort study of patients with cT1-T3N0 rectal cancer who underwent proctectomies between 2016 and 2022 in the National Surgical Quality Improvement Project proctectomy files. Multivariable logistic regression was used to identify factors associated with abdominoperineal resections and Kendall's tau statistics to evaluate clinical-pathological staging agreement.

RESULTS

In all, 3078 patients (29.6% cT1-2N0, 70.4% cT3N0) were included with 55.3% of tumours <5 cm from the anal verge. Overall, 58.2% received neoadjuvant therapy within 3 months of surgery (30.6% for cT1-T2N0 vs. 69.8% for cT3N0, P < 0.001), and 58.6% underwent abdominoperineal resection (55.5% for cT1-T2N0 vs. 59.9% for cT3N0, P = 0.058). The adjusted odds of undergoing abdominoperineal resection were associated with increasing age (OR 1.4 per every 10-year increase; 95% CI 1.2-1.5), cT3N0 tumours (OR 1.7; 95% CI 1.1-2.7) and tumour location <5 cm from the anal verge (OR 10.6; 95% CI 7.7-14.7). There was a weak clinical-pathological T staging correlation (Kendal tau coefficient 0.25; 95% CI 0.20-0.29).

CONCLUSION

In this large cohort of patients with early-stage rectal cancer with high rates of neoadjuvant therapy, over half of patients underwent abdominoperineal resection and one in five had a pathological complete response. These findings underscore opportunities for organ preservation in early-stage rectal cancer, suggesting that treatments typically reserved for locally advanced disease may extend to early stages with the completion of ongoing clinical trials.

Shared Decision-Making, Sphincter Preservation, and Rectal Cancer Treatment: Identifying and Executing What Matters Most to Patients

Rectal cancer treatment often encompasses multiple steps and options, with benefits and risks that vary based on the individual. Additionally, patients facing rectal cancer often have preferences regarding overall quality of life, which includes bowel function, sphincter preservation, and ostomies. This article reviews these data in the context of shared decision-making approaches in an effort to better inform patients deliberating treatment options for rectal cancer.

Perineal bowel evisceration after extralevator abdominoperineal excision and vertical rectus abdominis myocutaneous flap closure

INTRODUCTION

Perineal bowel evisceration is a rare complication after extralevator abdominoperineal excision (ELAPE). This surgical technique is used to resect low rectal and anal cancer, with a lower likelihood of positive surgical margins, but resulting in a larger perineal defect. A vertical rectus abdominis myocutaneous (VRAM) flap allows filling of the empty pelvic space and closure of the defect in the pelvic floor.

CASE PRESENTATION

A 77-year-old woman, with a hysterectomy in her medical history, underwent an ELAPE followed by reconstruction of the perineal defect with a VRAM flap after neoadjuvant radiotherapy for a moderately differentiated invasive adenocarcinoma of the distal rectum. The postoperative course was complicated with a herniation of the perineal wound and evisceration of a bowel loop.

CONCLUSION

Closure of the perineal defect after ELAPE remains a challenge, especially in cases where several risk factors for delayed wound healing, flap failure and perineal herniation are present.

Comparison of oncological outcomes between low anterior resection and abdominoperineal resection for rectal cancer: A retrospective cohort study using a multicenter database in Japan

BACKGROUND

It remains controversial whether the abdominoperineal resection (APR) procedure itself has a negative impact on prognosis compared with sphincter-saving surgery (SSS). The purpose of this study was to investigate whether the operation type affects the prognostic outcome in rectal cancer using a multicenter database in Japan.

METHODS

The study involved 2533 patients who underwent APR or SSS and were registered in the Japanese Society for Cancer of the Colon and Rectum database, which includes data from 74 centers, between 2003 and 2007. The primary endpoints were overall survival (OS) and relapse-free survival (RFS). The secondary endpoints were local recurrence rate (LRR) and pathological radial margin (pRM) status.

RESULTS

Multivariate analysis identified pathological tumor depth, lymph node status, and pRM status to be associated with oncological outcomes (OS, RFS, LRR). Although the oncological outcomes were worse after APR than after SSS in univariate analysis, there was no significant difference in OS (hazard ratio 1.08; 95% confidence interval [CI] 0.85-1.37) or RFS (hazard ratio 1.06; 95% CI 0.87-1.30) between APR and SSS. There was also no significant difference in LRR (odds ratio 1.11, 95% CI 0.70-1.77). Multivariate analysis showed that operation type was associated with positive pRM (odds ratio 3.13, 95% CI 0.18-0.56).

CONCLUSIONS

There was no significant difference in oncological outcomes between APR and SSS for rectal cancer. The risk of positive pRM was higher for APR and performing radial margin-negative surgery is an important factor in improving the oncological outcomes of APR.

How We Treat Localized Rectal Cancer-An Institutional Paradigm for Total Neoadjuvant Therapy

Total neoadjuvant therapy (TNT)-the neoadjuvant employment of radiotherapy (RT) or chemoradiation (CRT) as well as chemotherapy (CHT) before surgery-may lead to increased pathological complete response (pCR) rates as well as a reduction in the risk of distant metastases in locally advanced rectal cancer. Furthermore, increased response rates may allow organ-sparing strategies in a growing number of patients with low rectal cancer and upfront immunotherapy has shown very promising early results in patients with microsatellite instability (MSI)-high/mismatch-repair-deficient (dMMR) tumors. Despite the lack of a generally accepted treatment standard, we strongly believe that existing data is sufficient to adopt the concept of TNT and immunotherapy in clinical practice. The treatment algorithm presented in the following is based on our interpretation of the current data and should serve as a practical guide for treating physicians-without any claim to general validity.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group's practical consensus statements for surgical management of localized and locally advanced rectal cancer

INTRODUCTION

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

METHODS

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

RESULTS

Using the results of the review of the literature and experts' opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as "strong or weak", based on the GRADE framework.

CONCLUSION

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons' community in India.

Outcomes and Cost Analysis of Robotic Versus Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Case-Matched Study

BACKGROUND

Although laparoscopy for abdominoperineal resection has been well defined, the literature lacks comparative studies on robotic abdominoperineal resection. Because robotic abdominoperineal resections typically do not require splenic mobilization or an anastomosis for reconstruction, the mean console time is expected to be shorter than low anterior resection. We hypothesized that robotic and laparoscopic abdominoperineal resection would provide similar oncologic and financial outcomes.

OBJECTIVE

The study aimed to compare the perioperative, oncologic, and economic outcomes of the robotic and laparoscopic abdominoperineal resection.

DESIGN

This was a retrospective, case-matched patient cohort.

SETTINGS

This study was conducted at a tertiary referral center.

PATIENTS

This study included all patients who underwent either laparoscopic or robotic abdominoperineal resections between January 2008 and April 2017; they were case-matched in a 1:1 ratio based on age ±5 years, BMI ±3 kg/m 2 , and sex criteria.

MAIN OUTCOME MEASURES

Perioperative, oncologic, and economic (including survival) outcomes were compared. Because of institutional policy, actual cost values are presented as the lowest direct cost value as "100%," and other values are presented as proportional to the index value.

RESULTS

We examined 68 patients (34 in each group). Both groups had similar preoperative characteristics, including preoperative chemoradiation rates. Operative time (319 vs 309 min), length of stay (7.2 vs 7.4 d), postoperative complications (38.2% vs 41.2%), conversion to open (5 vs 4), complete mesorectal excision (76.4% vs 79.4%), radial margin involvement (2.9% vs 8.9%), and direct hospital cost parameters (mean difference 26%, median difference 43%) were comparable between robotic and laparoscopic abdominoperineal resection groups, respectively (all p > 0.05). Local recurrence, disease-free survival, and overall survival rates (85.3% vs 76.5%) were also similar after 22 months of follow-up between the groups.

LIMITATIONS

The main limitations of this study are its retrospective nature and the variety in concomitant procedures.

CONCLUSIONS

Robotic abdominoperineal resections provided in carefully matched patients with rectal cancer showed similar perioperative and short-term oncologic outcomes compared to laparoscopic abdominoperineal resections. Our study was not powered to detect a significant increase in cost with robotic abdominoperineal resections. See Video Abstract at http://links.lww.com/DCR/B920 .

RESULTADOS Y ANLISIS DE COSTO DE LA RESECCIN ABDOMINOPERINEAL LAPAROSCPICA VS LA ROBTICA EN CASOS DE CNCER DE RECTO ESTUDIO DE CASOS EMPAREJADOS

ANTECEDENTES:Si bien la resección abdominoperineal laparoscópica está bien definida, la literatura carece de estudios comparativos sobre la resección abdominoperineal robótica. Dado que las resecciones abdominoperineales robóticas generalmente no requieren movilización esplénica o una anastomosis en casos de reconstrucción, se supone que el tiempo medio en la consola sea más corto que durante una resección anterior baja. Hipotéticamente las resecciones abdominoperineales robóticas y laparoscópicas nos proporcionarían resultados oncológicos y económicos similares.OBJETIVO:Comparar los resultados perioperatorios, oncológicos y económicos de la resección abdominoperineal robótica y laparoscópica.DISEÑO:Esta fue una cohorte de pacientes retrospectiva, emparejada por casos.AJUSTE:Estudio realizado en un centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a resecciones abdominoperineales LAParoscópicas o ROBóticas entre Enero de 2008 y Abril de 2017 fueron identificados y emparejados según la edad ±5, el IMC ±3 y los criterios de sexo en una proporción de 1:1.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados perioperatorios, oncológicos y económicos (incluida la sobrevida). Debido a la política institucional, los valores de costos reales se presentan como el valor de costo directo más bajo al 100% y los otros valores se presentan como proporcionales al valor índice.RESULTADOS:Se analizaron 68 pacientes (LAP-34 y ROB-34). Ambos grupos tenían características preoperatorias similares, incluidas las tasas de radio-quimioterapia pre-operatoria. Los tiempos operatorios fueron de 319 y 309 minutos, la estadía hospitalaria de 7 días en los dos grupos, las complicaciones post-operatorias fueron de 38,2% LAP frente a 41,2% ROB, la tasa de conversion fué de 5 a 4, la excisión total del mesorrecto de 76,4% frente a 79,4%, la resección radial con afectación de los márgenes de 2,9% frente a 8,9% y los parámetros de costes hospitalarios directos (diferencia de medias 26%, diferencia de medianas 43%) fueron comparables entre los grupos, de resección abdominoperineal robótica y laparoscópica, respectivamente (todos p > 0,05). Las tasas de recurrencia local, sobrevida libre de enfermedad y sobrevida general (85,3% frente a 76,5%) también fueron similares después de 22 meses de seguimiento entre los grupos.LIMITACIONES:La naturaleza retrospectiva y la variedad de procedimientos concomitantes fueron las principales limitaciones de este estudio.CONCLUSIONES:Las resecciones abdominoperineales robóticas proporcionaron resultados oncológicos perioperatorios y a corto plazo similares en pacientes con cáncer de recto cuidadosamente emparejados en comparación con las resecciones abdominoperineales laparoscópicas. Nuestro estudio no fue diseñado para detectar un aumento significativo en el costo relacionado con la resección abdominoperineal robótica. Consulte Video Resumen en http://links.lww.com/DCR/B920 . (Traducción-Dr. Xavier Delgadillo ).

Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment

Background

Extralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes.

Methods

Medical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed.

Results

The mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%.

Conclusions

Laparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10019-2.

Transanal total mesorectal excision combined with intersphincteric resection has similar long-term oncological outcomes to laparoscopic abdominoperineal resection in low rectal cancer: a propensity score-matched cohort study

Background

Transanal total mesorectal excision (taTME) or intersphincteric resection (ISR) has recently proven to be a valid and safe surgical procedure for low rectal cancer. However, studies focusing on the combination of these two technologies are limited. This study aimed to evaluate perioperative results, long-term oncologic outcomes, and anorectal functions of patients with low rectal cancer undergoing taTME combined with ISR, by comparing with those of patients undergoing laparoscopic abdominoperineal resection (laAPR).

Methods

After 1:1 propensity score matching, 200 patients with low rectal cancer who underwent laAPR (n = 100) or taTME combined with ISR (n = 100) between September 2013 and November 2019 were included. Patient demographics, clinicopathological characteristics, oncological outcomes, and anal functional results were analysed.

Results

Patients in the taTME-combined-with-ISR group had less intraoperative blood loss (79.6 ± 72.6 vs 107.3 ± 65.1 mL, P = 0.005) and a lower rate of post-operative complications (22.0% vs 44.0%, P < 0.001) than those in the laAPR group. The overall local recurrence rates were 7.0% in both groups within 3 years after surgery. The 3-year disease-free survival rates were 86.3% in the taTME-combined-with-ISR group and 75.1% in the laAPR group (P = 0.056), while the 3-year overall survival rates were 96.7% and 94.2%, respectively (P = 0.319). There were 39 patients (45.3%) in the taTME-combined-with-ISR group who developed major low anterior resection syndrome, whereas 61 patients (70.9%) had good post-operative anal function (Wexner incontinence score ≤ 10).

Conclusion

We found similar long-term oncological outcomes for patients with low rectal cancer undergoing laAPR and those undergoing taTME combined with ISR. Patients receiving taTME combined with ISR had acceptable post-operative anorectal function.

Transperineal pelvic drainage combined with lateral position to promote perineal wound healing after abdominoperineal resection: A prospective cohort trial

BACKGROUND

For the rectal cancer <5 cm from anal margin, extralevator abdominoperineal resection (eAPR) has been accepted widely by surgeons. However, the rate of perineal infection following up eAPR is approximately 70%. We did the study with the aim of evaluating the effect and safety of transperineal pelvic drainage combined with lateral position (TPDLP) on perineal wound in patients undergoing eAPR.

METHODS

Patients were randomly assigned to N-TPDLP group (standard arm) or TPDLP group (intervention arm). In the standard arm, surgery was completed after abdominal drainage tube was placed in pelvic. Comparatively, an additional transperineal wound drainage tube was applied in the experimental arm. Postoperatively, patients of both 2 groups were informed not to sit to reduce perineal compression until the perineal wound healed. But lateral position was demanded in the intervention arm. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of <2 at 30 days postoperatively. Patients were followed for 6 months.

RESULTS

In total, 60 patients were randomly assigned to standard arm (n = 31) and intervention arm (n = 29). The mean perineal wound healing time was 34.2 (standard deviation [SD] 10.9) days in TPDLP arm, which significantly differ from 56.4 (SD 34.1) in N-TPDLP arm (P = .001). At 30 days postoperatively, 3 (10%) of 29 patients undergoing TPDLP were classified into grade 4 according to Southampton wound score, however, 16 (52%) of 31 patients were classified into grade 4 in control arm, and significantly difference was observed between randomization groups (P = .001). What's more, perineal wound pain was assessed at 30 days postoperatively, and it is discovered that the pain degree of patients in control arm was significantly more severe than the interventive arm (P = .015).

CONCLUSION

In the present study, we found that TPDLP generated a favorable prognosis for perineal wounds with acceptable side-effects.

Rectal washout during abdominoperineal resection for rectal cancer has no impact on the oncological outcome

AIM

Intraoperative rectal washout is performed to eliminate exfoliated intraluminal cancer cells and thereby decrease the risk of local recurrence. Rectal washout in abdominoperineal resection has not been studied. The aim of this study was to assess the oncological outcome after rectal washout in abdominoperineal resection for rectal cancer and to find evidence as to whether rectal washout should be performed or not.

METHOD

Data for all patients registered in the Swedish Colorectal Cancer Registry who underwent elective surgery with abdominoperineal resection for rectal cancer (TNM Stages I-III) between 2007 and 2013 were analysed using multivariable analysis.

RESULTS

No significant differences were shown between the rectal washout group and the no rectal washout group for local recurrence [10/265 (3.8%) vs. 87/2160 (4.0%), p = 0.84], distant metastasis [51/265 (19.2%) vs. 476/2160 (22.0%), p = 0.29] or overall recurrence [53/265 (20.0%) vs. 505/2160 (23.4%), p = 0.21]. In multivariable analysis, rectal washout did not significantly affect the oncological outcome in terms of local recurrence, distant metastasis, overall recurrence or 5-year overall or relative survival.

CONCLUSION

Our results do not support routine rectal washout during abdominoperineal resection in order to improve the oncological outcome.

Dataset for Pathology Reporting of Colorectal Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR)

OBJECTIVE

The aim of this study to describe a new international dataset for pathology reporting of colorectal cancer surgical specimens, produced under the auspices of the International Collaboration on Cancer Reporting (ICCR).

BACKGROUND

Quality of pathology reporting and mutual understanding between colorectal surgeon, pathologist and oncologist are vital to patient management. Some pathology parameters are prone to variable interpretation, resulting in differing positions adopted by existing national datasets.

METHODS

The ICCR, a global alliance of major pathology institutions with links to international cancer organizations, has developed and ratified a rigorous and efficient process for the development of evidence-based, structured datasets for pathology reporting of common cancers. Here we describe the production of a dataset for colorectal cancer resection specimens by a multidisciplinary panel of internationally recognized experts.

RESULTS

The agreed dataset comprises eighteen core (essential) and seven non-core (recommended) elements identified from a review of current evidence. Areas of contention are addressed, some highly relevant to surgical practice, with the aim of standardizing multidisciplinary discussion. The summation of all core elements is considered to be the minimum reporting standard for individual cases. Commentary is provided, explaining each element's clinical relevance, definitions to be applied where appropriate for the agreed list of value options and the rationale for considering the element as core or non-core.

CONCLUSIONS

This first internationally agreed dataset for colorectal cancer pathology reporting promotes standardization of pathology reporting and enhanced clinicopathological communication. Widespread adoption will facilitate international comparisons, multinational clinical trials and help to improve the management of colorectal cancer globally.

Surgical Techniques for Abdominoperineal Resection for Rectal Cancer: One Size Does Not Fit All

Abdominoperineal resection (APR) of rectal cancer is associated with poorer oncological outcomes than anterior resection. This may be due to higher rates of intra-operative perforation (IOP) and circumferential resection margin (CRM) involvement causing higher recurrence rates and surgical complications. To address these concerns, several centers advocated a change in technique from a standard APR to a more radical extra-levator abdominoperineal excision (ELAPE). Initial reports showed that ELAPE reduced IOP rates and CRM involvement but increased wound complications and longer surgical duration. However, many of these studies had unacceptable rates of IOP and CRM before retraining in ELAPE. This may indicate that it was a sub-optimal surgical technique, which improved upon training, that had influenced the high CRM and IOP rates rather than the technique itself. Subsequent studies demonstrated that the CRM involvement rate for ELAPE was not always lower than for standard APR and, in some cases, significantly higher. The morbidity of ELAPE can be high, with studies reporting higher adverse events than APR, especially in terms of wound complications from the larger perineal incision required in ELAPE. Whether ELAPE improves short- or long-term oncological outcomes for patients has not been clearly demonstrated. The authors propose that all centers performing rectal cancer surgery audit surgical outcomes of patients undergoing APR or ELAPE and examine CRM involvement, IOP rates, and local recurrence rates, preferably through a national body. If rates of adverse technical or oncological outcomes exceed acceptable levels, then retraining in the appropriate surgical techniques may be indicated.

Hospital variation in sphincter-preservation rates in rectal cancer treatment: results of a population-based study in the Netherlands

Background

This study aimed to examine the sphincter-preservation rate variations in rectal cancer surgery. The influence of hospital volume on sphincter-preservation rates and short-term outcomes (anastomotic leakage (AL), positive circumferential resection margin (CRM), 30- and 90-day mortality rates) were also analysed.

Methods

Non-metastasized rectal cancer patients treated between 2009 and 2016 were selected from the Netherlands Cancer Registry. Surgical procedures were divided into sphincter-preserving surgery and an end colostomy group. Multivariable logistic regression models were generated to estimate the probability of undergoing sphincter-preserving surgery according to the hospital of surgery and tumour height (low, 5 cm or less, mid, more than 5 cm to 10 cm, and high, more than 10 cm). The influence of annual hospital volume (less than 20, 20–39, more than 40 resections) on sphincter-preservation rate and short-term outcomes was also examined.

Results

A total of 20 959 patients were included (11 611 sphincter preservation and 8079 end colostomy) and the observed median sphincter-preservation rate in low, mid and high rectal cancer was 29.3, 75.6 and 87.9 per cent respectively. After case-mix adjustment, hospital of surgery was a significant factor for patients’ likelihood for sphincter preservation in all three subgroups (P < 0.001). In mid rectal cancer, borderline higher rates of sphincter preservation were associated with low-volume hospitals (odds ratio 1.20, 95 per cent c.i. 1.01 to 1.43). No significant association between annual hospital volume and sphincter-preservation rate in low and high rectal cancer nor short-term outcomes (AL, positive CRM rate and 30- and 90-day mortality rates) was identified.

Conclusion

This population-based study showed a significant hospital variation in sphincter-preservation rates in rectal surgery. The annual hospital volume, however, was not associated with sphincter-preservation rates in low, and high rectal cancer nor with other short-term outcomes.

Usefulness of Endoscopic Tattooing Before Neoadjuvant Therapy in Patients with Clinical Complete Response in Locally Advanced Rectal Cancer for Providing a Safe Distal Surgical Margin

Background: Endoscopic tattooing of colorectal tumors enables tumor localization and determination of appropriate surgical margins. It becomes very difficult to detect the distal surgical margins (DSMs) of rectal tumors in patients who obtain clinical complete response (cCR) after neoadjuvant therapy. In this study, our aim is to examine the benefits of endoscopic tattooing of the tumor before neoadjuvant therapy in patients with locally advanced rectal cancer in accurate localization of the previous tumor and in providing appropriate DSMs in cases with cCR. Patients and Methods: The patients who were diagnosed with locally advanced rectal cancer, received neoadjuvant therapy and subsequently achieved cCR, and underwent surgery between January 2015 and October 2020 were included in the study. The patients were divided into two groups according to whether they were endoscopically tattooed before neoadjuvant chemoradiotherapy. Results: A total of 49 cases were included in the study. Significantly better DSMs were observed especially in female gender in the tattooed group. DSMs were found to be closer to the resection margins in the nontattooed group. It was found that endoscopic tattooing had a significant effect on the DSM in the regression analysis (P = .06, R² = 0.47). It was determined that laparoscopy or open surgery alone did not differ in terms of DSMs but open surgery together with tattooing was found to be strongly effective in providing larger DSMs. Conclusion: In locally advanced rectal cancer, endoscopic tattooing of the distal margin of the tumor before neoadjuvant therapy is a reliable and effective method for obtaining a safe DSM and not leaving the residual tumor at the lower end of anastomosis, especially in cases of cCR.

A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival

PURPOSE

Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach.

METHODS

This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures.

RESULTS

A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively.

CONCLUSION

Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Functional outcome and quality of life following treatment for rectal cancer

Introduction Over the last decades, treatment for rectal cancer has substantially improved with development of new surgical options and treatment modalities. With the improvement of survival, functional outcome and quality of life are getting more attention.

Study objective To provide an overview of current modalities in rectal cancer treatment, with particular emphasis on functional outcomes and quality of life.

Results Functional outcomes after rectal cancer treatment are influenced by patient and tumor characteristics, surgical technique, the use of preoperative radiotherapy and the method and level of anastomosis. Sphincter preserving surgery for low rectal cancer often results in poor functional outcomes that impair quality of life, referred to as low anterior resection syndrome. Abdominoperineal resection imposes the need for a permanent stoma but avoids the risk of this syndrome. Contrary to general belief, long-term quality of life in patients with a permanent stoma is similar to those after sphincter preserving surgery for low rectal cancer.

Conclusion All patients should be informed about the risks of treatment modalities. Decision on rectal cancer treatment should be individualized since not all patients may benefit from a sphincter preserving surgery “at any price”. Non-resection treatment should be the future focus to avoid the need of a permanent stoma and bowel dysfunction.

A new surgical approach of direct perineal wound full-thick closure for perineal wound of abdominoperineal resection for rectal carcinoma: A prospective cohort trial

Perineal wound complications after APR have high morbidity in the colorectal surgical department. Although some approaches have been figured out to solve this clinical focus, the outcomes are still not satisfied. Herein, this prospective comparative clinical trial has been designed to evaluate a new surgical procedure of direct perineal wound full-thick closure (DPWC), compared with conventional perineal wound closure (CPWC), with hopes of making wound healing with less complications. In addition, an evaluation of an incision negative wound pressure therapy, as another focus in this field, was also analysed in the DPWC group. A total of 44 participants in our department were recruited from March 2018 to March 2020, divided into two groups randomly, CPWC group and DPWC group. The patients' characteristics, such as age, gender, BMI, smoking, alcohol consumption, comorbidities, CEA level, and high-risk of invasion, were recorded without statistical significance between the CPWC group and DPWC group. After the same standard abdominal phase, these two groups were performed in different perineal phases. And then, operative and postoperative outcomes were analysed with different statistical methods. Data on wound healing time and length of stay in the DPWC group were shorter than those in the CPWC group (P < .05). Furthermore, cases of wound infection within 30 days in the DPWC group were also less than that in the CPWC group (P < .05). However, no difference was found between the incisional negative pressure wound therapy assisted group (NPA group) and non- incisional negative pressure wound therapy assisted group (non-NPA group). During this study, hypoalbuminemia, as an independent high-risk factor, impacted perineal wound healing. (P = .0271) In conclusion, DPWC is a new surgical approach, which can lead to a better outcome than DPWC, and it can be another surgical procedure for clinicians. In addition, hypoalbuminemia should be interfered for avoiding perineal wound complications.

Gender aspects of survival after abdominoperineal resection for low rectal cancer: a retrospective study

PURPOSE

The difference in prognosis between genders after abdominoperineal resection (APR) for low rectal cancer (LRC) is unclear. This study aimed to compare survival outcomes between genders in patients with LRC who underwent curative APR.

METHODS

This retrospective cohort study used a database of consecutive colorectal resections. Patients who received curative APR with LRC were grouped according to their gender. Female patients were frequency-matched 1:1 on American Joint Committee on Cancer (AJCC) stage to male patients. Overall survival (OS), disease-free survival (DFS), and their independent risk factors were examined.

RESULTS

A total of 140 patients with APR for LRC were included after matching: 70 (50.0%) males and 70 (50.0%) females. No significant differences were found between the groups in terms of age, operation methods, AJCC stage, and adjuvant therapy (all P > 0.05). Median follow-up was 39 (range: 3-128) months. Male gender was independently associated with worse OS (adjusted hazard ratio [HR] = 2.755, 95% CI: 1.507-5.038, P = 0.001) and worse DFS (adjusted HR = 2.440, 95% CI: 1.254-4.746, P = 0.009). Subgroup analysis revealed that female patients with stage III disease had better OS (P = 0.001) and DFS (P < 0.001) than male patients.

CONCLUSION

Gender affects survival after a curative APR for LRC. Compared with females, male patients with LRC after curative APR had worse prognosis, especially for stage III disease.

Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study

AIM

The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh.

METHOD

One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain).

RESULTS

A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P = 0.07). The median period between surgery and hernia diagnosis was 8 months in the primary closure group and 24 months in the mesh group (P < 0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P < 0.01).

CONCLUSION

In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.

Sphincter-saving surgery for ultra-low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long-term follow-up?

BACKGROUND

Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR).

METHODS

ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection.

RESULTS

Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%).

CONCLUSION

GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.

Avoiding urethral and rectal injury during transperineal abdominoperineal resection in male patients with anorectal cancer

BACKGROUND

In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach.

METHODS

We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video.

RESULTS

Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation.

CONCLUSIONS

The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.

Radiomic Texture and Shape Descriptors of the Rectal Environment on Post-Chemoradiation T2-Weighted MRI are Associated with Pathologic Tumor Stage Regression in Rectal Cancers: A Retrospective, Multi-Institution Study

(1) Background: The relatively poor expert restaging accuracy of MRI in rectal cancer after neoadjuvant chemoradiation may be due to the difficulties in visual assessment of residual tumor on post-treatment MRI. In order to capture underlying tissue alterations and morphologic changes in rectal structures occurring due to the treatment, we hypothesized that radiomics texture and shape descriptors of the rectal environment (e.g., wall, lumen) on post-chemoradiation T2-weighted (T2w) MRI may be associated with tumor regression after neoadjuvant chemoradiation therapy (nCRT). (2) Methods: A total of 94 rectal cancer patients were retrospectively identified from three collaborating institutions, for whom a 1.5 or 3T T2w MRI was available after nCRT and prior to surgical resection. The rectal wall and the lumen were annotated by an expert radiologist on all MRIs, based on which 191 texture descriptors and 198 shape descriptors were extracted for each patient. (3) Results: Top-ranked features associated with pathologic tumor-stage regression were identified via cross-validation on a discovery set (n = 52, 1 institution) and evaluated via discriminant analysis in hold-out validation (n = 42, 2 institutions). The best performing features for distinguishing low (ypT0-2) and high (ypT3-4) pathologic tumor stages after nCRT comprised directional gradient texture expression and morphologic shape differences in the entire rectal wall and lumen. Not only were these radiomic features found to be resilient to variations in magnetic field strength and expert segmentations, a quadratic discriminant model combining them yielded consistent performance across multiple institutions (hold-out AUC of 0.73). (4) Conclusions: Radiomic texture and shape descriptors of the rectal wall from post-treatment T2w MRIs may be associated with low and high pathologic tumor stage after neoadjuvant chemoradiation therapy and generalized across variations between scanners and institutions.

Clinical parameters predictive for sphincter-preserving surgery and prognostic outcome in patients with locally advanced low rectal cancer

Background

Although controversial, there are data suggesting that clinical parameters can predict the probability of sphincter preserving procedures in rectal cancer. The purpose of this study was to investigate the association between clinical parameters and the sphincter-preserving surgery rate in patients who had undergone neoadjuvant combination therapy for advanced low rectal cancer.

Methods

In this single center study, the charts of 540 patients with locally advanced rectal cancer who had been treated with induction chemotherapy-and/or neoadjuvant concomitant radiochemotherapy (nRCT) over an 11-year period were reviewed in order to identify patients with rectal cancer ≤6 cm from the anal verge, who had received the prescribed nRCT only. Univariate and multivariate analyses were used to identify pretreatment patient- and tumor associated parameters correlating with sphincter preservation. Survival rates were calculated using Kaplan-Meier analyses.

Results

Two hundred eighty of the 540 patients met the selection criteria. Of the 280 patients included in the study, 158 (56.4%) underwent sphincter-preserving surgery. One hundred sixty-four of 280 patients (58.6%) had a downsizing of the primary tumor (ypT < cT) and 39 (23.8%) of these showed a complete histopathological response (ypT0 ypN0). In univariate analysis, age prior to treatment, Karnofsky performance status, clinical T-size, relative lymphocyte value, CRP value, and interval between nRCT and surgery, were significantly associated with sphincter-preserving surgery. In multivariate analysis, age (hazard ratio (HR) = 1.05, CI95%: 1.02–1.09, p = 0.003), relative lymphocyte value (HR = 0.94, CI95%: 0.89–0.99, p = 0.029), and interval between nRCT and surgery (HR = 2.39, CI95%: 1.17–4.88, p = 0.016) remained as independent predictive parameters.

Conclusions

These clinical parameters can be considered in the prognostication of sphincter-preserving surgery in case of low rectal adenocarcinoma. More future research is required in this area.

Predictors of Early Distant Relapse in Rectal Cancer Patients Submitted to Preoperative Chemoradiotherapy

BACKGROUND

Neoadjuvant chemoradiotherapy (CRT) is a standard treatment for locally advanced rectal cancer. CRT leads to a better local control; however, this does not translate into a survival benefit. Long-term survival is mostly affected by the development of distant metastases after surgery. This study aimed to evaluate predictive clinical factors for the development of early metastatic disease after CRT.

METHODS

Clinical data of patients with stage II/III rectal cancer submitted to CRT between January 2000 and October 2014 were collected from prospectively maintained electronic databases of three Italian institutes. Patients were divided into two groups: those who developed metastasis within 12 months from surgical resection (Group A) and patients without or with late distant relapse (Group B).

RESULTS

Among 635 patients, 86 (13.5%) had early distant relapse within 1 year from surgery (Group A), and 549 (86.5%) did not (Group B). A higher rate of early distant relapse was associated with CEA levels above 3 ng/dL (20% vs. 10%; p <0.001), tumor lying under 5 cm from anal verge (20% vs. 9%; p <0.001), and age under 63 years (17% vs. 11%; p = 0.036). Multivariate analysis confirmed these factors to be independently correlated with a higher risk of early metastasis.

CONCLUSIONS

Younger age, low tumors, and high serum CEA may be associated with unfavorable early oncological outcomes after CRT and surgery for rectal cancer. These clinical factors could be useful to select patients for more aggressive therapeutic strategies.

Locally recurrent rectal cancer: what the radiologist should know

Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.

Precise Three-Dimensional Morphology of the Male Anterior Anorectum Reconstructed From Large Serial Histologic Sections: A Cadaveric Study

BACKGROUND

Deep anatomic knowledge of the male anterior anorectum is important to avoid urethral injury and rectal perforation in intersphincteric resection or abdominoperineal resection for very low rectal cancer. However, its structure is difficult to understand, because the anorectum, muscles, and urogenital organs are complicatedly and 3-dimensionally arranged.

OBJECTIVE

The purpose of this study was to revisit the anatomic information of the male anterior anorectum for intersphincteric resection and abdominoperineal resection with a focus on the spatial muscular morphology.

DESIGN

This was a descriptive cadaveric study.

SETTINGS

The study was conducted at Ehime and Kyoto universities.

PATIENTS

Tissue specimens from 9 male cadavers were included.

MAIN OUTCOME MEASURES

Specimens around the anterior anorectum were serially sectioned in the horizontal, sagittal, or frontal plane; large semiserial histologic sections were created at 250-μm intervals. The series were stained with Elastica van Gieson, and some sections from the series were studied by immunohistochemistry to detect smooth and striated muscles. Two series were digitalized and reconstructed 3-dimensionally.

RESULTS

Two regions without a clear anatomic border were elucidated: 1) the anterior region of the external anal sphincter, where the external anal sphincter, bulbospongiosus muscle, and superficial transverse perineal muscle were intertwined; and 2) the rectourethralis muscle, where the smooth muscle of the longitudinal muscle continuously extended to the posteroinferior area of the urethra, which became closest to the anorectum at the prostatic apex level. A tight connection between the striated and smooth muscles was identified at the anterior part of the upper external anal sphincter and anterolateral part of the puborectalis muscle level.

LIMITATIONS

This study involved a small sample size of elderly cadavers.

CONCLUSIONS

This study clarified the precise spatial relationship between smooth and striated muscles. The detailed anatomic findings will contribute more accurate step-by-step anterior dissection in intersphincteric resection and abdominoperineal resection, especially with the transanal approach, which can magnify the muscle fiber direction and contraction of striated muscle by electrostimulation. MORFOLOGÍA TRIDIMENSIONAL PRECISA DEL ANORRECTO ANTERIOR MASCULINO RECONSTRUIDO A TRAVÉS DE SECCIONES MAYORES HISTOLÓGICAS EN SERIE: UN ESTUDIO CADAVÉRICO: El conocimiento anatómico amplio del anorrecto anterior masculino es importante para evitar lesiones de uretra y perforación de recto en la resección interesfinterica o la resección abdominoperineal para cáncer de recto bajo. Sin embargo, su estructura es difícil de entender porque el anorrecto, los músculos y los órganos urogenitales están aliñados en forma complexa tridimensional.

OBJETIVO

Revisar de nuevo el conocimiento anatómico del anorrecto anterior masculino relevante a la resección interesfinterica y la resección abdominoperineal con un enfoque en la morfología muscular espacial. DISEÑO:: Estudio descriptivo cadavérico.

ENTORNO

Ehime y la Universidad de Kyoto.

SUJETOS

Tejido especímenes de nueve cadáveres masculinos. PUNTOS FINALES DE VALORACIÓN:: Las muestras alrededor del anorrecto anterior se seccionaron en serie en planos horizontal, sagital y coronal. Se crearon mayores secciones histológicas en serie a intervalos de 250 μm. Los especímenes fueron teñidos con Elástica van Gieson, y algunas secciones de la serie se estudiaron mediante inmunohistoquímica para detectar músculos lisos y estriados. Dos series fueron digitalizadas y reconstruidas tridimensionalmente.

RESULTADOS

Se demostraron dos regiones sin un borde anatómico definido: (i) la región anterior del esfínter anal externo, donde se entrelazaron el esfínter anal externo, el músculo bulbospongoso y el músculo perineal transverso superficial; y (ii) músculo rectouretral, donde el músculo liso del músculo longitudinal se extiende continuamente a la zona posteroinferior de la uretra, que se acerca más al anorrecto a nivel del ápice prostático. La conexión estrecha entre los músculos estriados y lisos se identificó en la parte anterior del esfínter anal externo superior y la parte anterolateral del nivel del músculo puborrectal. LIMITACIÓN:: Este estudio incluyó una muestra pequeña de cadáveres ancianos. CONCLUSIÓN:: Este estudio aclaró la relación espacial precisa entre los músculos lisos y estriados. Los hallazgos anatómicos detallados ayudarán para una disección anterior paso a paso más precisa en la resección interesfintérica y la resección abdominoperineal, especialmente con el abordaje transanal, que puede magnificar la dirección de las fibras musculares y la contracción del músculo estriado utilizando electroestimulación.

Multicenter study of surgical and oncologic outcomes of extra-levator versus conventional abdominoperineal excision for lower rectal cancer

BACKGROUND

The surgical and oncological outcome of extra-levator abdominoperineal excision (ELAPE) procedure remains unclear in low rectal cancer.

METHODS

A total of 194 cases of rectal cancer patients underwent ELAPE or conventional abdominoperineal excision (APE) procedure were analyzed in four hospitals' databases from January 2010 to December 2015. Clinicopathological data, overall survival (OS), disease free survival (DFS) and local recurrence free survival (LRFS) of patients were compared between two groups.

RESULTS

The operation time spent in perineal phase was significantly shorter in the ELAPE group than that in conventional APE procedure (P < 0.001). There were more specimens with excellent or good quality in ELAPE group compared to conventional APE group (P = 0.033). Patients whom underwent ELAPE procedures showed significantly better OS, DFS and LRFS than those underwent conventional APE procedures. Patients with preoperative stage cT3∼T4 (P = 0.033, P = 0.008, P = 0,033), cN+ (P = 0.002, P < 0.001, P = 0.006) and pathological stage III-IV (P = 0.023, P = 0.008, P = 0.016) were associated with significant benefits from ELAPE procedure in terms of OS, DFS and LRFS. DFS differed significantly between two groups of patients whom got preoperative chemoradiation therapy (P = 0.009) or postoperative chemotherapy (P = 0.029). For patients of pathological stage IIII-IV without preoperative chemoradiation, ELAPE procedures resulted in statistically better OS (P = 0.018) and DFS (P = 0.030). ELAPE procedure was an independent risk factor of OS, DFS and LRFS in multivariate analysis.

CONCLUSION

Low rectal cancer patients might benefit from ELAPE procedure on both surgical and oncological outcomes, especially in patients with relatively advanced tumors, inspite of the effects of pre-operative radio- and chemotherapy.

Oncologic outcomes for low rectal adenocarcinoma following low anterior resection with coloanal anastomosis versus abdominoperineal resection: a National Cancer Database propensity matched analysis

PURPOSE

Low anterior resection with coloanal anastomosis (CAA) for low rectal cancer is a technically difficult operation with limited data available on oncologic outcomes. We aim to investigate overall survival and operative oncologic outcomes in patients who underwent CAA compared to abdominoperineal resection (APR).

METHODS

The National Cancer Database (2004-2013) was used to identify patients with non-metastatic rectal adenocarcinoma who underwent CAA or APR. Patients were 1:1 matched on age, gender, Charlson score, tumor size, tumor grade, pathologic stage, and radiation treatment with propensity scores. The primary outcome was overall survival. Secondary outcomes included 30-day mortality and resection margins.

RESULTS

Following matching, 3536 patients remained in each group. No significant differences in matched demographic, treatment, or tumor variables were seen between groups. There was no significant difference in 30-day mortality (1.24% vs. 1.39%, p = 0.60). Following resection, margins were more likely to be negative after CAA compared with APR (5.26% vs. 8.14%, p < 0.001). When stratified by pathologic stage, there was a significant survival advantage for individuals undergoing CAA compared to APR (stage 1 HR 0.72, [95% CI 0.62-0.85], p < 0.001; stage 2 HR 0.76, [95% CI 0.65-0.88], p < 0.001; stage 3 HR 0.76, [95% CI 0.67-0.85], p < 0.001).

CONCLUSIONS

Patients undergoing CAA compared with APR for rectal cancer have better overall survival and are less likely to have positive margins despite the technically challenging operation.

Influence of Body Mass Index on Long-Term Outcome in Patients with Rectal Cancer-A Single Centre Experience

BACKGROUND

Excess bodyweight is known to influence the risk of colorectal cancer; however, little evidence exists for the influence of the body mass index (BMI) on the long-term outcome of patients with rectal cancer.

METHODS

We assessed the impact of the BMI on the risk of local recurrence, distant metastasis and overall-survival in 612 patients between 2003 and 2010 after rectal cancer diagnosis and treatment at the University Hospital Erlangen. A Cox-regression model was used to estimate the hazard ratio and multivariate risk of mortality and distant-metastasis. Median follow up-time was 58 months.

RESULTS

Patients with obesity class II or higher (BMI ≥ 35 kg/m², n = 25) and patients with underweight (BMI < 18.5 kg/m², n = 5) had reduced overall survival (hazard ratio (HR) = 1.6; 95% confidence interval (CI) 0.9-2.7) as well as higher rates of distant metastases (hazard ratio HR = 1.7; 95% CI 0.9-3.3) as compared to patients with normal bodyweight (18.5 ≤ BMI < 25 kg/m², n = 209), overweight (25 ≤ BMI <30 kg/m², n = 257) or obesity class I (30 ≤ BMI <35 kg/m², n = 102). There were no significant differences for local recurrence.

CONCLUSIONS

Underweight and excess bodyweight are associated with lower overall survival and higher rates of distant metastasis in patients with rectal cancer.

Long-term Oncologic Outcomes After Neoadjuvant Chemoradiation Followed by Intersphincteric Resection With Coloanal Anastomosis for Locally Advanced Low Rectal Cancer

BACKGROUND

To date only few data have been available relating to the oncologic safety of intersphincteric resection in such advanced tumors.

OBJECTIVE

This study aimed to elucidate the oncologic outcomes and clinical factors affecting the long-term survival of patients who underwent preoperative chemoradiotherapy followed by intersphincteric resection for locally advanced rectal cancers.

DESIGN

This was a retrospective analysis of prospectively collected departmental data.

SETTINGS

The study was conducted at a department of colorectal surgery in a tertiary care teaching hospital between January 2009 and September 2015.

PATIENTS

A cohort of 147 consecutive patients with low rectal cancer undergoing intersphincteric resection after preoperative chemoradiotherapy was included.

MAIN OUTCOME MEASURES

Kaplan-Meier analyses were used to evaluate the 3-year disease-free survival and local recurrence rates. Logistic regression analyses were used to analyze the influence of tumor response and other prognostic factors on survival outcomes.

RESULTS

Median follow-up was 34 months (range, 8-94 mo). The estimated overall 3-year disease-free survival and local recurrence rates were 64.9% and 11.7%. Circumferential resection margin involvement and pathologic T stage (ypT stage) were significant predictors of cancer relapse. The 3-year disease-free survival was 47.4% for patients with ypT3 tumors compared with 82.0% for those with ypT0-2 tumors (p = 0.001). The 3-year disease-free survival was 36.5% for patients with involved circumferential resection margins compared with 69.7% for those with a noninvolved circumferential resection margin (p = 0.003). On multivariate analysis, ypT stage, ymrT stage, and circumferential resection margin status were associated with worse disease-free survival. Clinical T-stage and pathologic distal margin status were not independent factors affecting oncologic outcomes.

LIMITATIONS

This study is limited with respect to its retrospective design.

CONCLUSIONS

In these patients with locally advanced low rectal cancers, intersphincteric resection after preoperative chemoradiotherapy was associated with acceptable oncologic outcomes. See Video Abstract at http://links.lww.com/DCR/A941.

Postanal minimally invasive surgery "PAMIS" assisted extra-levator abdominoperineal excision "ELAPE" for cancer: A novel approach in supine position

Local recurrences are more common after abdominoperineal excision (APE) than after anterior resection of rectal cancer. Extralevator APE was introduced to address this problem. The post anal minimally invasive approach had been used by other authors for transperineal mesh rectopexy but not in cancer management. Our aim is to use the post-anal minimally invasive approach for better visualization and division of the levator Ani during the Extralevator abdominoprineal excision in 2 cases of carcinoma of the anal canal. After laparoscopic exploration of the abdomen and performing a laparoscopic nerve sparing TME down to the levator ani from the abdominal side, the perineal phase was started by a purse string suture followed by a postanal incision and division of the Anococcygeal ligament, the gel port was inserted where visualization of the levator ani allows its division under vision posteriorly and laterally in order to achieve a good circumferential resection margin in the studied 2 cases. Good circumferential resection margin was reported pathologically and photographed in one of them. Postanal minimally invasive PAMIS assisted technique facilitates the extralevator abdominoperineal "ELAPE" in supine position. However a large multicenter trial comparing this new assisted technique with the traditional ELAPE id needed for a final conclusion.

Surgical outcome after standard abdominoperineal resection: A 15-year cohort study from a single cancer centre

BACKGROUND

Abdominoperineal resection (APR) is associated with a poorer oncological outcome than anterior resection. This may be due to higher rates of intra-operative perforation and circumferential resection margin involvement. The aim of this study was to audit our short and long-term results of abdominoperineal resection performed using conventional techniques and to compare this with other published series.

MATERIALS AND METHODS

A retrospective review of all patients who had standard APR between January 2000 and December 2016 in a single institution, Cabrini Hospital, Melbourne, Australia. A total of 163 cases performed by nine different colorectal surgeons for primary rectal adenocarcinoma were identified, with their clinicopathological data analysed.

RESULTS

Using standard APR, only six patients (3.7%) were found to have a positive circumferential resection margin (CRM). There were two cases of intra-operative perforation (1.2%). Local recurrence rate was 5.6% of patients, with distant recurrence found in 24.9%. Disease-free survival at five years was 73.1%. Five-year overall survival was 66.7%, 67.9% of all deaths were cancer-related.

CONCLUSION

Short and long-term outcomes after standard APR in this study were comparable to previous published studies. The CRM rate of 3.7% compares favourably to published positive CRM rates for standard APR which ranged from 6 to 18%. Standard APR remains a viable technique for the treatment of rectal cancer. Patient selection and adequate training remain important factors.

Immediate Perineal Reconstruction After Extralevatory Abdominoperineal Excision: Buried Desepidermised Fasciocutaneous V-Y Advancement Flap

BACKGROUND

According to National Cancer Institute, there are approximately 39,800 rectal cancer cases per year, 25% of which will need an abdominoperineal resection (APR). The key to avoid most of the complications related to pelvic defect that occurs after APR is choosing an appropriate reconstruction option for perineum. This study aims to introduce an easily applicable flap option for closure to address postoperative pelvic defect in low rectal cancer.

METHODS

This is a retrospective evaluation of 9 patients who have undergone perineal reconstruction for pelvic defects after extralevatory abdominoperineal excision with rectal cancer between 2014 and 2016. Reconstruction consists of a novel technique defined by our clinic, which is buried desepidermised fasciocutaneous V-Y advancement flap.

RESULTS

All defects are closed successfully. Patients are followed postoperatively for complications such as perineal infection, wound dehiscence, seroma, perineal sinus, or fistula formation. Flaps are evaluated with magnetic resonance imaging postoperatively, for viability and effectiveness on defect closure. Mean follow-up time is 20 (±9) months. Mean average hospital stay is 8 (±2) days. We did not experience any total or partial flap loss or encounter any local complication related to the wound.

CONCLUSIONS

Buried desepidermised fasciocutaneous V-Y advancement flap is a reasonably easy and time-saving operation. It is effective in filling the pelvic dead space while closing the sacral defect after APR and therefore decreases late term complications related to large perineal excision.

Abdominoperineal Resection for Rectal Cancer in the Twenty-First Century: Indications, Techniques, and Outcomes

BACKGROUND

Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals.

DISCUSSION

In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.

Meta-analysis of histopathological outcomes of laparoscopic assisted rectal resection (LARR) vs open rectal resection (ORR) for carcinoma

BACKGROUND

We conducted a meta-analysis of the randomized evidence to determine the relative merits of histopathological outcomes of laparoscopic assisted (LARR) versus open rectal resection (ORR) for rectal cancer.

DATA SOURCES

A search of PubMed and other electronic databases comparing LARR and ORR between Jan 2000 and June 2016 was performed. Histopathological variables analyzed included; location of rectal tumors; complete and incomplete TME; positive and negative circumferential resection margins (+/-CRM); positive distal resected margins (+DRM); distance of tumor from DRM; number of lymph nodes harvested; resected specimen length; tumor size and perforated rectum.

RESULTS

Fourteen RCTs totaling 3843 patients (LARR = 2096, ORR = 1747) were analyzed. Comparable effects were noted for all these histopathological variables except for the variable perforated rectum which favored ORR.

CONCLUSIONS

LARR compares favorably to ORR for rectal cancer treatment. However, there is significantly higher risk of rectal perforation during LARR compared to ORR.

Association between operative technique and intrusive thoughts on health-related Quality of Life 3 years after APE/ELAPE for rectal cancer: results from a national Swedish cohort with comparison with normative Swedish data

The aim of this prospective registry‐based population study was to investigate the association between QoL 3 years after surgery for rectal cancer and intrusive thoughts and to assess the association with the type of surgery (i.e., APE or ELAPE) in a population‐based national cohort. ELAPE has been proposed as a superior surgical technique for distal rectal cancer, but long‐term effects on QoL are not known. There are also no studies on the association of negative intrusive thoughts on patients′ self‐reported Quality of Life following surgery for distal rectal cancer. Negative intrusive thoughts are regarded as a marker of incomplete cognitive processing of the psychological trauma caused by, for example, a cancer diagnosis. Intrusive thoughts have been recognized as an important factor associated Quality of Life outcome following surgery for other malignancies. All Swedish patients operated with any kind of abdominoperineal resection in the years 2007–2009 were identified through the Swedish ColoRectal Cancer Registry (SCRCR)—the APER population. All patients alive 3 years after surgery and willing to participate were included. Data were collected from three different sources: the registry, the original operative notes, and a study‐specific questionnaire regarding health‐related QoL answered by the patients. Questions on QoL from a normative reference population were also collected for comparison. Fifty‐six percent of the APER population reported a low overall Quality of Life. There was no significant difference between the sexes. Among men, there was a difference in overall QoL, with a higher level in the normative population (48%) compared with the male APER population (39%). Overall QoL was compared to a normative Swedish population. Almost half of the patients experienced negative intrusive thoughts, which was associated with a lower overall Quality of Life. The frequency and severity of negative intrusive thoughts were significantly associated with a low overall QoL. There was no difference in overall QoL after standard, compared with extralevator abdominoperineal excision. A large proportion of survivors after abdominoperineal excision for rectal cancer has a Quality of Life compared with a normative population, but many suffer from negative intrusive thoughts, a symptom of stress, which significantly decrease overall Quality of Life.

Minimally Invasive Surgery for Rectal Cancer: Current Status and Future Perspectives

Although laparoscopic resection for colon cancer has been proven safe and feasible when compared with open resection, currently no clear evidence is available regarding minimally invasive surgery for rectal cancer. This type of surgery may benefit patients by allowing fast recovery of normal dietary intake and bowel function, reduced postoperative pain, and shorter hospitalization. Therefore, minimally invasive surgeries such as laparoscopic or robot surgery have become the predominant treatment option for colon cancer. Specifically, the proportion of laparoscopic colorectal cancer surgery in Korea increased from 42.6 to 64.7% until 2013. However, laparoscopic surgery for rectal cancer is more difficult and technically demanding. In addition, the procedure requires a prolonged learning curve to achieve equivalent outcomes relative to open surgery. It is very challenging to approach the deep and narrow pelvis using laparoscopic instruments. However, robotic surgery provides better vision with a high definition three-dimensional view, exceptional ergonomics, Endowrist technology, enhanced dexterity of movement, and a lack of physiologic tremor, facilitated by the use of an assistant in the narrow and deep pelvis. Recently, an increasing number of reports have compared the outcomes of laparoscopic and open surgery for colon cancer. Such reports have prompted a discussion of the outcomes of minimally invasive surgery, including robotic surgery, for rectal cancer. The aim of this review is to summarize current data regarding the clinical outcomes, including oncologic outcomes, of minimally invasive surgery for rectal cancer.

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors

BACKGROUND

Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity.

METHODS

Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed.

RESULTS

All procedures were successfully completed without conversion. Average body mass index was 32 kg/m². The mean operative time and blood loss were 370 min and 130 ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14 months, all patients remain disease-free.

CONCLUSIONS

Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.

Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer

Treatment results in rectal cancer have improved significantly during the recent two decades, but local control and survival after abdominoperineal excision (APE) have not improved to the same degree as that seen after anterior resection (AR). The reason for this is an increased risk of inadvertent bowel perforations and tumor involved margins after APE as compared with AR. The conventional synchronous combined APE has not been a standardized procedure and consequently oncological outcomes have varied considerably between different institutions and in different reports. With the new concept of APE, based on well-defined anatomical structures, the procedure can be categorized as intersphincteric APE, extralevator APE, and ischioanal APE. This article discusses the technical aspects and results from this approach.