Has adherence to treatment guidelines for mid/low rectal cancer affected the management of patients? A monocentric study of 604 consecutive patients

Guideline- Versus Non-Guideline-Based Neoadjuvant Management of Clinical T4 Rectal Cancer

(1) Background: Practice guidelines recommend neoadjuvant treatment for clinical T4 rectal cancer. The primary objective of this retrospective study was to assess whether compliance with guidelines correlates with patient outcomes. Secondarily, we evaluated predictors of adherence to guidelines and mortality. (2) Methods: A total of 397 qualified rectal cancer (RC) patients from 2017 to 2020 at West China Hospital of Sichuan University were included. Patients were divided into two groups depending on adherence to neoadjuvant treatment guidelines. The main endpoints were overall survival (OS) and disease special survival (DSS). We analyzed factors associated with guideline adherence and mortality. (3) Results: Compliance with guidelines was only 39.55%. Patients' neoadjuvant therapy treated not according to the guidelines for clinical T4 RC was not associated with an overall survival (95.7% vs. 88.9%) and disease special survival (96.3% vs. 91.1%) benefit. Patients were more likely to get recommended therapy with positive patient compliance. Staging Ⅲ, medium/high differentiation and objective compliance were associated with increased risk of mortality. (4) Conclusions: Guideline adherence for clinical T4 RC in our system is low. Compliance with the relevant guidelines for neoadjuvant therapy seems not to lead to better overall survival for patients with clinical T4 RC.

Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think

Objectives

This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state.

Methods

We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method.

Results

Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01).

Conclusions

This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.

Abdominal adipose tissue quantification and distribution with CT: prognostic value for surgical and oncological outcome in patients with rectal cancer

OBJECTIVES

Obesity is a known factor of poor surgical and oncological outcomes in patients who undergo surgery for colorectal cancer. There are physiological differences between abdominal visceral and subcutaneous adipose tissue. Evaluation of its quantity and distribution is possible with routine clinical imaging techniques, such as computed tomography. The goal of this study was to explore the associations and find correlations of fat measurements and distribution with surgical morbidity, long-term mortality and disease progression in patients who underwent surgery for rectal cancer.

METHODS

Patients who underwent rectal cancer resection between 2006 and 2016 were included in this retrospective study. Computed tomography fat area measurements were assessed on preoperative computed tomography scans and were compared with postoperative outcomes (local and general complications), long-term survival and oncological response.

RESULTS

Of 202 patients included, 50 (25%) died with a median survival time of 34 months, and 152 (75%) were still alive at the end of the study. Death and disease progression were significantly associated with a high intermuscular/subcutaneous fat ratio at the L4-L5 level, with a cut-off established at 0.12 (p < 0.05). Patients with a low (< 1.15) subcutaneous/visceral fat ratio at the L2-L3 level experienced significantly more local complications (p < 0.05).

CONCLUSIONS

This study suggests that patients with a low subcutaneous fat area/visceral fat area ratio had more local postoperative complications and that a high intermuscular fat area/subcutaneous fat area ratio was associated with worse survival outcomes, as well as a high postoperative complication rate.

KEY POINTS

• A low subcutaneous/visceral fat ratio seems to be associated with more local postsurgery complications in patients with rectal cancer, while a high intermuscular/subcutaneous fat ratio seems to be associated with worse survival and oncological outcomes. • A high intermuscular/subcutaneous fat ratio seems to be associated with worse survival outcomes or progressing disease, as well as a higher postoperative complication rate. • Computed tomography abdominal fat area measurements are correlated with one another on multiple anatomical levels.

Influence of non-clinical factors on restorative rectal cancer surgery: An analysis of four specialized population-based digestive cancer registries in France

BACKGROUND

This study aims to measure the association between deprivation, health care accessibility and health care system with the likelihood of receiving non-restorative rectal cancer surgery (NRRCS).

METHODS

All adult patients who had rectal resection for invasive adenocarcinoma diagnosed between 2007 and 2016 in four French specialised cancer registries were included. A multilevel logistic regression with random effect was used to assess the link between patient and health care structure characteristics on the probability of NRRCS.

RESULTS

2997 patients underwent rectal cancer resection in 68 health care structures: 708 (23.63%) had NRRCS. The likelihood of receiving NRCCS was associated with patients' characteristics (97%): age, sub peritoneal rectal tumors, neoadjuvant therapy, residual tumour and stage III . There was no impact of European Deprivation Index or remoteness on NRRCS. Inter-health care structure variability was modest (3%), of which 50% was explained by the high group volume of colorectal procedures and the type of health care structure which were associated with less NRRCS (p<0.01).

CONCLUSION

There is an influence of operating volume and type of structure on the probability of NRRCS, but it has truly little importance in explaining differences in performances. The probability of NRRCS is mainly affected by clinical determinant.

Are oncological long-term outcomes equal after laproscopic completed and converted laparoscopic converted rectal resection for cancer?

BACKGROUND

The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer.

METHODS

All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively.

RESULTS

Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS.

CONCLUSIONS

This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.