Multivisceral resections for rectal cancers: short-term oncological and clinical outcomes from a tertiary-care center in India

Roles of MRI evaluation of pelvic recurrence in patients with rectal cancer

Developments in the multidisciplinary treatment of rectal cancer with advances in preoperative magnetic resonance imaging (MRI), surgical techniques, neoadjuvant chemoradiotherapy, and adjuvant chemotherapy have had a significant impact on patient outcomes, increasing the rates of curative surgeries and reducing pelvic recurrence. Patients with pelvic recurrence have worse prognoses, with an impact on morbidity and mortality. Although local recurrence is more frequent within 2 years of surgical resection of the primary tumor, late recurrence may occur. Clinical manifestations can vary from asymptomatic, nonspecific symptoms, to pelvic pain, bleeding, and fistulas. Synchronous metastatic disease occurs in approximately 50% of patients diagnosed with local recurrence. MRI plays a crucial role in posttreatment follow-up, whether by identifying viable neoplastic tissues or acting as a tool for therapeutic planning and assessing the resectability of these lesions. Locally recurrent tissues usually have a higher signal intensity than muscle on T2-weighted imaging. Thus, attention is required for focal heterogeneous lesions, marked contrast enhancement, early invasive behavior, and asymmetric appearance, which are suspicious for local recurrence. However, postsurgical inflammatory changes related to radiotherapy and fibrosis make it difficult to detect initial lesions. This study therefore aimed to review the main imaging patterns of pelvic recurrence and their implications for the surgical decision-making process. CRITICAL RELEVANCE STATEMENT: MRI plays a crucial role in the posttreatment follow-up of rectal cancer, whether by identifying viable neoplastic tissues or by acting as a tool for therapeutic planning. This study reviewed the main imaging patterns of pelvic recurrence. KEY POINTS: MRI aids in surgical planning and the detection of pelvic recurrence and postoperative complications. Being familiar with surgical techniques enables radiologists to identify expected MRI findings. Patterns of rectal cancer recurrence have been categorized by pelvic compartments. Neoplastic tissue may mimic postsurgical and postradiotherapy changes. Resectability of pelvic recurrence is highly related to lesion location.

Multivisceral resection of advanced colon and rectal cancer: a prospective multicenter observational study with propensity score analysis of the morbidity, mortality, and survival

Objectives

In the surgical treatment of colorectal carcinoma (CRC), 1 in 10 patients has a peritumorous adhesion or tumor infiltration in the adjacent tissue or organs. Accordingly, multivisceral resection (MVR) must be performed in these patients. This prospective multicenter observational study aimed to analyze the possible differences between non-multivisceral resection (nMVR) and MVR in terms of early postoperative and long-term oncological treatment outcomes. We also aimed to determine the factors influencing overall survival.

Methods

The data of 25,321 patients from 364 hospitals who had undergone surgery for CRC (the Union for International Cancer Control stages I-III) during a defined period were evaluated. MVR was defined as (partial) resection of the tumor-bearing organ along with resection of the adherent and adjacent organs or tissues. In addition to the patients' personal, diagnosis (tumor findings), and therapy data, demographic data were also recorded and the early postoperative outcome was determined. Furthermore, the long-term survival of each patient was investigated, and a "matched-pair" analysis was performed.

Results

From 2008 to 2015, the MVR rates were 9.9 % (n=1,551) for colon cancer (colon CA) and 10.6 % (n=1,027) for rectal cancer (rectal CA). CRC was more common in men (colon CA: 53.4 %; rectal CA: 62.0 %) than in women; all MVR groups had high proportions of women (53.6 % vs. 55.2 %; pairs of values in previously mentioned order). Resection of another organ frequently occurred (75.6 % vs. 63.7 %). The MVR group had a high prevalence of intraoperative (5.8 %; 12.1 %) and postoperative surgical complications (30.8 % vs. 36.4 %; each p<0.001). Wound infections (colon CA: 7.1 %) and anastomotic insufficiencies (rectal CA: 8.3 %) frequently occurred after MVR. The morbidity rates of the MVR groups were also determined (43.7 % vs. 47.2 %). The hospital mortality rates were 4.9 % in the colon CA-related MVR group and 3.8 % in the rectal CA-related MVR group and were significantly increased compared with those of the nMVR group (both p<0.001). Results of the matched-pair analysis showed that the morbidity rates in both MVR groups (colon CA: 42.9 % vs. 34.3 %; rectal CA: 46.3 % vs. 37.2 %; each p<0.001) were significantly increased. The hospital lethality rate tended to increase in the colon CA-related MVR group (4.8 % vs. 3.7 %; p=0.084), while it significantly increased in the rectal CA-related MVR group (3.4 % vs. 3.0 %; p=0.005). Moreover, the 5-year (yr) overall survival rates were 53.9 % (nMVR: 69.5 %; p<0.001) in the colon CA group and 56.8 % (nMVR: 69.4 %; p<0.001) in the rectal CA group. Comparison of individual T stages (MVR vs. nMVR) showed no significant differences in the survival outcomes (p<0.05); however, according to the matched-pair analysis, a significant difference was observed in the survival outcomes of those with pT4 colon CA (40.6 % vs. 50.2 %; p=0.017). By contrast, the local recurrence rates after MVR were not significantly different (7.0 % vs. 5.8 %; both p>0.05). The risk factors common to both tumor types were advanced age (>79 yr), pT stage, sex, and morbidity (each hazard ratio: >1; p<0.05).

Conclusions

MVR allows curation by R0 resection with adequate long-term survival. For colon or rectal CA, MVR tended to be associated with reduced 5-year overall survival rates (significant only for pT4 colon CA based on the MPA results), as well as, with a significant increase in morbidity rates in both tumor entities. In the overall data, MVR was associated with significant increases in hospital lethality rates, as indicated by the matched-pair analysis (significant only for rectal CA).

Minimally Invasive Surgery for Pelvic Exenteration in Primary Colorectal Cancer

BACKGROUND

Minimally invasive surgery (MIS) for pelvic exenteration is not a well-established technique. The aim was to assess the safety and feasibility of MIS for pelvic exenteration in locally advanced primary colorectal cancer and to compare the perioperative outcomes with open surgery.

METHODS

This is a retrospective analysis of patients, who had undergone pelvic exenteration for primary colorectal adenocarcinoma from May 2013 to July 2018. The short-term outcomes like perioperative details and histopathological characteristics were compared between the two groups.

RESULTS

MIS was performed in 23 patients and open pelvic exenteration was carried out in 72 patients. The mean operative time was significantly more in the MIS group (640 vs. 432 min, p = 0.00). The intraoperative blood loss (900 vs. 1550 ml, p = 0.00) and the requirement for blood transfusion (170 vs. 250 ml, p = 0.03) was significantly less in the MIS group. The overall morbidity (60% vs. 49%, p = 0.306) was comparable between the two groups. The median length of hospital stay in the MIS group was 11 d, compared to 12 d in the open surgery group, (p = 0.634). The rate of R0 resection (87% vs. 89%, p = 0.668) was comparable between the two groups.

CONCLUSION

MIS is feasible and safe for total pelvic exenteration and posterior exenteration in carefully selected locally advanced primary colorectal cancer, when performed by an experienced surgical team in high volume centers. An R0 resection with adequate margin can be achieved with good perioperative outcomes in MIS. Long-term oncological outcomes would require further follow up to confirm.

Laparoscopic Pelvic Exenteration for Locally Advanced Rectal Cancer, Technique and Short-Term Outcomes

Background: Since last two decades minimally invasive techniques have revolutionized surgical field. In 2003 Pomel first described laparoscopic pelvic exenteration, since then very few reports have described minimally invasive approaches for total pelvic exenteration. Methods: We report the 10 cases of locally advanced rectal adenocarcinoma which were operated between the periods from March 1, 2017 to November 11, 2017 at the Tata Memorial Hospital, Mumbai. All male patients had lower rectal cancer with prostate involvement on magnetic resonance imaging (MRI). One female patient had uterine and fornix involvement. All perioperative and intraoperative parameters were collected retrospectively from prospectively maintained electronic data. Results: Nine male patients with diagnosis of nonmetastatic locally advanced lower rectal adenocarcinoma were selected. All patients were operated with minimally invasive approach. All patients underwent abdominoperineal resection with permanent sigmoid stoma. Ileal conduit was constructed with Bricker's procedure through small infraumbilical incision (4-5 cm). Lateral pelvic lymph node dissection was done only when postchemoradiotherapy MRI showed enlarged pelvic nodes. All 10 patients received neoadjuvant chemo radiotherapy, whereas 8 patients received additional neoadjuvant chemotherapy. Mean body mass index was 21.73 (range 19.5-26.3). Mean blood loss was 1000 mL (range 300-2000 mL). Mean duration of surgery was 9.13 hours (range 7-13 hours). One patient developed paralytic ileus, which was managed conservatively. One patient developed intestinal obstruction due to herniation of small intestine behind the left ureter and ileal conduit. The same patient developed acute pylonephritis, which was managed with antibiotics. Mean postoperative stay was 14.6 days (range 9-25 days). On postoperative histopathology, all margins were free of tumor in all cases. Conclusion: Minimally invasive approaches can be used safely for total pelvic exenteration in locally advanced lower rectal adenocarcinoma. All patients had fast recovery with less blood loss. In all patients R0 resection was achieved with adequate margins. Long-term oncological outcomes are still uncertain and will require further follow-up.