Middle Rectal Cancer Research Articles

Đánh giá chất lượng cuộc sống của bệnh nhân ung thư trực tràng trên và giữa được điều trị phẫu thuật nội soi cắt trực tràng trước thấp

Introduction: Evaluation of the quality of life of patients with upper and middle rectal cancer treated with laparoscopic low anterior resection. Material and method: Prospective and previous research from 1/2013 to 9/2019 at Hue central hospital, a laparoscopic low anterior resection was performed in 86 patients with upper and mid rectal cancer. Result: There were 40 males and 45 females with the mean age of 62,95 ± 13,13; no conversion, have seven cases anastomotic leakage. Mean follow-up duration 60 months: have five cases local recurrence (5,9%), the overall survival rate after 5 years was 45%. Quality of Life of Patients is quiet good. Conclusion: Laparoscopic low anterior resection for treatment upper and mid rectal cancer is safe and effective, quality of life of patient is quite good.

CIRUGIA RADICAL DEL CANCER DEL RECTO LOCALMENTE AVANZADO. ANALISIS COMPARATIVO DE LA CIRUGÍA LAPAROSCOPICA CON LA CIRUGÍA ABIERTA

Introducción: El tratamiento estándar del cáncer del recto localmente avanzado (CRLA) actual es multimodal. La cirugía mínimamente invasiva es factible en el manejo de este tumor, aunque existe controversia sobre sus resultados alejados.Objetivo: Comparar los resultados inmediatos y alejados de una serie laparoscópica (CL) con una serie de cirugía convencional (CA) intervenidos por CRLA.Material y método: Revisión retrospectiva de ambas técnicas de abordaje en un periodo de 14 años. Se analiza la morbilidad, los resultados patológicos, la recidiva local y la sobrevida a largo plazo. Para estimar las curvas de sobrevida se utilizó el método de Kaplan-Meier. Para comparar las curvas de sobrevida se usó el test de log-rank.Resultados: Se compara 163 pacientes intervenidos por CL con 164 operados mediante CA. Ambos grupos resultaron equivalentes en cuanto a las variables demográficas, morbilidad perioperatoria y estadios patológicos finales, salvo un menor tiempo de hospitalización en el grupo CL (p=0,007). Los tumores bajos recibieron radioterapia preoperatoria en el 90% de los casos. La recidiva local global y la sobrevida a largo plazo no muestra diferencias de acuerdo al tipo de abordaje. Al excluir los pacientes con una lesión en el recto superior se aprecia que los tumores de recto bajo tienen peor pronóstico, independiente de la técnica empleada (p=0,007).Conclusiones: La CL es equivalente a la CA en el manejo multimodal del CRLA. La inclusión de tumores del recto superior tiende a mejorar artificialmente los resultados de la cirugía en cuanto a recidiva local y sobrevida global.

Time interval between the completion of radiotherapy and robotic-assisted surgery among patients with stage I-III rectal cancer undergoing preoperative chemoradiotherapy.

BackgroundThis aim of this study was to evaluate the effects of time interval between the completion of radiotherapy and robotic-assisted surgery on the outcomes among patients with rectal cancer undergoing preoperative concurrent chemoradiotherapy (CCRT).MethodsIn total, 116 patients with stage I–III rectal cancer who underwent preoperative CCRT and robotic-assisted surgery between September 2013 and February 2019 were enrolled. Patients were categorized into two groups based on the time interval: group A (10–12 weeks) and group B (≥ 12 weeks).ResultsAmong the 116 enrolled patients, 98 (84.5%) had middle and lower rectal cancers. Two (1.7%) patients underwent abdominoperineal resection with a sphincter preservation rate of 98.3%. Thirty-seven (31.9%) patients had a pathologic complete response (pCR). The circumferential resection margin and distal resection margin were positive in 2 (1.7%) and 1 (0.9%) patients, respectively. Therefore, the R0 resection rate was 97.4%. A total of 24 (22.4%) patients experienced postoperative relapse and 12 (10.3%) patients died; these were slightly more common in group B than in group A (28.8% vs 15.8% and 15.3% vs 5.3%, respectively; both P > 0.05); however, this difference was nonsignificant. Three-year disease-free survival (DFS) and overall survival (OS) were 75% and 89%, respectively, among all patients. Non-significant trend of favorable 3-year DFS, 3-year OS, 3-year locoregional control rate and 3-year distant metastasis control rate were observed in group A compared with group B (all P > 0.05).ConclusionRobotic-assisted surgery after a longer interval is safe and feasible for patients with rectal cancer undergoing preoperative CCRT. The present study’s results suggested that the time interval of 10–12 weeks can be considered because comparable clinical and perioperative outcomes and preferable oncological outcomes were observed for interval of this length. However, future prospective randomized clinical trials are required to verify the present finding.

Advanced distal rectal cancer: possibilities of sphincter-sparing surgeries in combination with neoadjuvant therapy

Objective: to analyze the outcomes of sphincter-sparing surgeries in patients with advanced distal rectal cancer depending on the therapy they receive.Materials and methods. This study included 289 patients with advanced (stage T3N0–2M0) distal rectal cancer who have undergone sphincter-sparing surgeries. Patients were divided into three groups according to their treatment scheme. In group 1, we used combination treatment that included a short course of neoadjuvant radiotherapy supplemented by 3 multidirectional radiomodifiers (local microwave hyperthermia, rectal administration of a biopolymer composition containing metronidazole, and chemotherapy with capecitabine). Patients in group 2 received combination treatment that included neoadjuvant radiotherapy alone. Treatment outcomes in patients receiving combination therapy was compared to those of patients with similar characteristics and location of rectal tumors who have undergone surgery alone in N. N. Blokhin National Medical Research Center of Oncology (group 3).Results. We observed a significant decrease in the incidence of locoregional cancer metastasis in patients from group 1 compared to those from groups 2 and 3 (0.8 % vs 7.9 % and 18.2 % respectively). Moreover, patients in group 1 demonstrated better relapse-free survival than participants in groups 2 and 3 (79.6 % vs 52.6 % and 51 % respectively). The new scheme of combination therapy developed by our team (used in group 1) did not increase the incidence of postoperative complications. The best local disease control in group 1 was achieved in patients with middle rectal cancer who have undergone sphincter-sparing surgeries: none of 81 patients developed relapses, whereas the relapse-free survival rate reached 83 % compared to 56.9 % in group 1 and 41.7 % in group 3.Conclusions. The new treatment scheme that includes neoadjuvant radiotherapy supplemented by 3 multidirectional radiomodifiers can be used as one of the options increasing efficacy of radiotherapy and, therefore, efficacy of combination treatment in patients with advanced rectal cancer who undergo sphincter-sparing surgeries.

Evaluation of the Extent of Mesorectal Invasion and Mesorectal Fascia Involvement in Patients with T3 Rectal Cancer With 2-D and 3-D Transrectal Ultrasound: A Pilot Comparison Study With Magnetic Resonance Imaging Findings

The aim of this study was to determine the value of 2-D and 3-D transrectal ultrasound (TRUS) in assessing the extent of mesorectal invasion (EMI) and mesorectal fascia involvement (MRF+) in patients with T3 rectal tumours. We retrospectively evaluated 80 patients with T3 stage rectal cancer who were pre-operatively evaluated by 2-D and 3-D TRUS before neoadjuvant chemoradiotherapy by using magnetic resonance imaging (MRI) as a reference standard. The T3 stage was subdivided into T3 ab (EMI ≤5 mm) and T3 cd (EMI >5 mm). The consistency assessment of the T3 sub-staging and MRF+ was compared between 2-D and 3-D TRUS using Cohen's kappa statistic. The concordance of the T3 sub-staging based on EMI was excellent between the 3-D TRUS and MRI (κ = 0.84) and good between the 2-D TRUS and MRI (κ = 0.67). For the assessment of MRF+ (κ = 0.82), 3-D TRUS and MRI showed excellent concordance. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 3-D TRUS for MRF+ assessment was 95.3%, 86.5%, 89.1% and 94.1%, respectively. The agreement between 3-D TRUS and MRI for the assessment of T3 sub-staging and MRF status was better in low rectal cancer (both κ = 0.85) than in middle (κ = 0.79 and 0.77) rectal cancer. Compared with MRI, 3-D TRUS has more advantages in the sub-staging of T3 rectal cancer and the assessment of MRF+ than those of 2-D TRUS, especially in low rectal cancer. For patients with T3 rectal cancer, 3-D TRUS may well complement MRI for selecting the appropriate treatment.

Risk factors of permanent stoma in rectal cancer patients undergoing transabdominal anterior resection with temporary stoma

Objective: To investigate the risk factors of turning temporary stoma into permanent stoma in rectal cancer patients undergoing transabdominal anterior resection with temporary stoma. Methods: A case-control study was carried out. Data of rectal cancer patients who underwent transabdominal anterior resection with temporary stoma and completed follow-up in Department of General Surgery of Xiangya Hospital of Central South University from June 2008 to June 2018 were collected and analyzed. In this study, temporary stoma included defunctioning stoma (ostomy was made during operation) and salvage stoma (ostomy was made within one month after operation due to anastomotic leakage or severe complications). Cases of multiple intestinal tumors were excluded. A total of 308 rectal cancer patients were enrolled in the study, including 198 males and 110 females with a median age of 56 (48-65) years. Ninety-four patients received intraperitoneal chemotherapy during operation. Among 308 patients, upper rectal cancer was observed in 64 cases, middle rectal cancer in 89 cases and low rectal cancer in 155 cases. Twenty patients underwent transverse colostomy and 288 underwent ileostomy. Phone call following-up was conducted from August to September 2019 to investigate whether stoma was reversed, causes of reversal failure, and tumor relapsed or not in detail. Permanent stoma was defined as that the stoma was still not reversed by the latest follow-up. The univariate analysis was performed with chi-square test or Fisher's exact test, and variables with P value < 0.10 were included in the non-conditional logistic regression model for multivariate analysis. Results: The median follow-up time was 54.3 (32.4-73.8) months. During follow-up, 8 cases had local recurrence and 37 cases had distant metastasis. Among the 308 patients with temporary ostomy, 247 (80.2%) patients had stomas reversed and the median interval time was 4.5 (3.5-6.1) months. The median interval time in 65 patients with salvage stoma was significantly longer that in 182 patients with defunctioning stoma [5.5 (4.3-7.5) vs. 4.2 (3.4-5.5) months; Z=-4.387, P<0.001]. The temporary ostomy was confirmed to become permanent stoma in 61 patients (19.8%), including 45 cases of defunctioning stoma and 16 cases of salvage stoma. Univariate analysis showed that preoperative anemia, intraperitoneal chemotherapy during operation, middle rectal cancer, transverse colostomy, pathological stage, postoperative local recurrence and distant metastasis were associated with permanent stoma (all P<0.10). Multivariate analysis revealed that the intraperitoneal chemotherapy during operation (OR=1.961, 95% CI: 1.029-3.738, P=0.041), middle rectal cancer (OR=2.401, 95% CI: 1.195-4.826, P=0.014), transverse colostomy (OR=3.433, 95% CI: 1.234-9.553, P=0.018), and distant metastasis (OR=8.282, 95% CI:3.820-17.954, P<0.001) were independent risk factors of permanent stoma. Conclusions: There is high risk of turning temporary stoma into permanent stoma among rectal cancer patients undergoing transabdominal anterior resection who receive intraperitoneal chemotherapy during operation, present as the middle rectal cancer, undergo transverse colostomy or develop distant metastasis. Surgeons need to evaluate and balance the risks and benefits thoroughly, and then inform the patients in order to avoid potential conflicts.

Value of 3Tesla MRI in the preoperative staging of mid‐low rectal cancer and its impact on clinical strategies

BackgroundTo determine the diagnostic accuracy of preoperative T/N stage with magnetic resonance imaging (MRI) in lower and middle rectal cancer patients and the impacts on clinical decision‐making.Patients and methodsA total of 211 patients were recruited from October 2015 to March 2017 in this retrospective study. High‐resolution MRI was performed within 2 weeks before surgery. Histopathologic results were evaluated for the postoperative T/N stage and the diagnostic accuracy of MRI was assessed according to the postoperative histopathologic results. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value were evaluated for T/N staging and κ values were used to evaluate MRI consistent analysis compared with postoperative histopathologic staging.ResultsThe overall MRI diagnostic accuracy was 79.62% for T1‐4 staging and 54.50% for N0‐2 staging. The κ values were 0.619 and 0.255 for T1‐4 and N0‐2 staging, respectively. The diagnostic accuracy of MRI for treatment decision‐making was 80.57%.ConclusionMRI allows a highly accurate preoperative assessment of T stage but only a fairly accurate preoperative assessment of N stage for rectal cancer. The diagnostic accuracy of MRI for treatment decision‐making is promising, but additional studies are needed to validate these findings in a larger sample size from multiple centers.

An Old Method Turnbull Cutait; Using for Middle and Distal Rectal Cancer Surgery without Ileostomy. Oncological and Fuctional Late Outcomes

An Old Method Turnbull Cutait; Using for Middle and Distal Rectal Cancer Surgery without Ileostomy. Oncological and Fuctional Late Outcomes

Assessment of T and N staging with MRI3T in lower and middle rectal cancer and impact on clinical strategy.

BackgroundTo determine the diagnostic accuracy of preoperative T/N stage using MRI in lower and middle rectal cancer patients and the impacts on clinical decision-making.Patients and methodsThere were 354 patients recruited from May 2017 to February 2019. MRI was performed within 2 weeks before surgery. Histopathologic results were evaluated for the postoperative T/N stage and MRI diagnostic accuracy was assessed based on the postoperative histopathologic results. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and Kappa values were used to evaluate MRI diagnostic accuracy and analysis consistency compared with postoperative histopathologic staging.ResultsOverall MRI diagnostic accuracy was 78.2% and 56.8% for T1–4 and N0–2 staging. The Kappa values were 0.625 and 0.323 for T1–4 and N0–2 staging, respectively. After combination, MRI diagnostic accuracy was 85% and 69.5% for T and N staging. The Kappa values were 0.693 and 0.4 for T and N staging. The diagnostic accuracy of MRI for treatment decision-making was 79.1%.ConclusionMRI enables a highly accurate preoperative assessment of T stage but only a fairly accurate preoperative assessment of the N stage for rectal cancer with surgery. The diagnostic accuracy of MRI for treatment decision-making is promising.

Laparoscopic and Robotic Surgery for Rectal Cancer—Comparative Study Between Two Centres

We compared short-term and long-term surgical and oncological outcomes of robotic surgery versus hand-assisted laparoscopic surgery for rectal cancers patients. Study was conducted at the National Cancer Institute and Yonsei Cancer Centre from August 2006 to December 2012. We prospectively reviewed all patients who underwent RS and HALS for upper and middle third rectal cancers. Patients’ demographics, postoperative short-term and long-term outcomes were assessed. Baseline patients’ characteristics were similar in both groups. Average operative time was 321.3 ± 70 min for robotic surgery versus 106.0 ± 37 min for hand-assisted laparoscopic surgery, P < 0.001). Higher number of patients (n = 74, 94.9%) with tumour in the upper rectum was found in hand-assisted laparoscopic group (P < 0.01). Perioperative complications were more common in the robotic surgery group (9 vs. 5 patients). In all stages, 3-year overall survival was 86.9% in the hand-assisted laparoscopic group vs. 89.6% in the robotic group: 80.0% vs. 79.2 for stage I and 82.4% vs. 88.9 for stage II and III. The 3-year DFS was 83.6% in hand-assisted laparoscopic group vs. 83.2%—robotic surgery group considering all stages. Anastomotic leakage, bleeding, number of postoperative complications, overall survival and disease-free survival were similar and not much different between robotic and hand-assisted laparoscopic rectal cancer surgery.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer.

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL). A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire. A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups. Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

The Influence of Neoadjuvant Chemoradiation for Middle and Lower Rectal Cancer on Anorectal Function.

To date, there is no clear understanding whether preoperative long-course chemoradiotherapy combined with surgery for rectal cancer is detrimental to anorectal function. The purpose of this study was to clarify the influence of preoperative chemoradiotherapy and surgery for middle and lower rectal cancer on postoperative anorectal function. Data of 113 patients with middle or lower rectal cancer treated with preoperative chemoradiotherapy plus surgery or surgery alone between January 2013 and December 2016 were analyzed. A total of 84 and 29 patients underwent low anterior resection and intersphincteric resection, respectively. In patients with T3 or deeper and with any N stage cancer below peritoneal reflection, surgery plus lateral lymph node dissection or preoperative radiation (total: 50.4 Gy/28 fractions) to the pelvis with chemoradiotherapy plus surgery was treated. Anorectal function was assessed prior to treatment and 6 and 12 months postoperatively. Specifically, maximum resting pressure and maximum squeezing pressures were measured. The Wexner score was recorded prior to treatment and 12 months postoperatively. maximum resting pressure and maximum squeezing pressure decreased post-surgery in both groups. Maximum resting pressure and maximum squeezing pressure at 12 months and the Wexner score at 12 months post-surgery were comparable among patients treated with chemoradiotherapy plus surgery and those treated with surgery alone. Preoperative chemoradiotherapy did not clearly impair postoperative anorectal function in patients who underwent low anterior resection and intersphincteric resection.

Our experience with transanal total mesorectal excision (TaTME) procedures in middle and distal rectal tumors.

Transanal total mesorectal excision (TaTME) is arelatively new approach in surgical treatment of rectal cancer. There are no clear indications when to choose this strategy. It is atechnically demanding procedure for the surgeon with along learning curve, which should also be taken into account in evaluation of this method. The results of both oncological and postoperative complications must be properly evaluated to explore the benefit of TaTME. The aim of this study is to assess the potential benefit of TaTME compared to other alternatives in middle and distal rectal tumors. Retrospective evaluation of patients undergoing TaTME procedure performed by one team of surgeons between October 2014 and June 2019. The authors analyzed demographic indicators of the group of patients, tumor characteristics, specimen quality, early postoperative complications and the possibility of stoma reversal. Atotal of 93 patients underwent TaTME procedure for middle and distal rectal cancer. Mean BMI was 27.6 (4.8). T3 or T4 tumor was found in 73 (78.5%) patients, 68 (73.1%) patients had positive lymph nodes and 12 (12.9%) patients were treated for synchronous metastatic rectal cancer. Neoadjuvant therapy was used in 80 (86%) patients. Conversion to open laparotomy was necessary in one case (1%). Stapled anastomosis was performed in 37 (39.7%) cases, handsewn in 56 (60.2%). Apositive circumferential resection margin (CRM) was found in 10 (10.7%) cases. Distal resection margin (DRM) was positive in 3 (3.2%) patients. Pathological analysis showed acomplete mesorectum in 18 patients (19.4%), nearly complete in 39 (41.9%) and an incomplete mesorectum in 36 (38.7%). Complications in the first 30 days after primary surgery were observed in 38 (40.8%) patients, mainly for anastomotic leak (19 patients, 20.4%). Reoperation was required in 7 (7.5%) patients. Permanent colostomy had to be performed in 4 (4.3%) cases. No patient died after surgery. In aselected group of patients it is possible to perform resection using this approach with acceptable postoperative morbidity and quality of the specimen. We used TaTME procedure in patients expected to have difficult TME due to obesity, size and distal localization of tumor. The incidence of conversion to open surgery was very low. Further studies for long term oncological outcomes are needed.

Mesorectal fat area and mesorectal area affect the surgical difficulty of robotic‐assisted mesorectal excision and intersphincteric resection respectively in different ways

Many studies have demonstrated predictors of the difficulty of laparoscopic anterior resection for rectal cancer. Few studies focus on the influence of pelvic dimensions on robotic-assisted mesorectal excision (ME) and intersphincteric resection (ISR). This study aimed to evaluate the influences of the mesorectal fat area (MFA) and mesorectal area on the difficulty of robotic sphincter-saving surgery. We included 156 patients with middle and low rectal cancer who underwent robotic sphincter-saving surgery. Clinical and anatomical factors, including the pelvic dimensions, were collected. Linear regression was performed for variables associated with surgical duration. We also performed subgroup analyses for robotic-assisted ME and ISR. Logistic regression was used to find variables associated with transanal dissection. For patients with middle or low rectal cancer, the sacral length and tumour distance from the anal verge were independently associated with surgical duration. The pT stage, sacral length and the MFA were independent predictors for the surgical duration of robotic-assisted ME. By contrast, a small mesorectal area was independently related to a longer duration of robotic-assisted ISR. The pelvic outlet length was independently associated with the use of transanal dissection for ISR. It is suggested that a large MFA could affect the difficulty of ME in robotic-assisted ME, while a small mesorectal area could increase the surgical difficulty of robotic-assisted ISR for low rectal cancer. Besides, the pelvic outlet length was associated with the use of transanal dissection. Further studies are needed to validate the results and draw more scientific conclusions.

Induction Chemotherapy for MRF-negative, Moderate-risk, Resectable Middle and Low Rectal Cancer

Induction Chemotherapy for MRF-negative, Moderate-risk, Resectable Middle and Low Rectal Cancer

Short-Term Clinical and Oncological Outcome of Prolonging Operation Interval After Neoadjuvant Chemoradiotherapy for Locally Advanced Middle and Low Rectal Cancer.

PurposeThe purpose of this study is to evaluate the short-term clinical and oncological outcome of prolonging operation interval to 11 weeks after the end of radiotherapy for locally advanced middle and low rectal cancer.MethodsA total of 123 patients with stage II/III (cT3/T4 or N+) low and middle rectal cancer who had undergone operation after neoadjuvant chemoradiotherapy were selected. According to the interval time between the last radiotherapy and operation, they were assigned to a short-interval group (SG, <11 weeks, n=66) and long-interval group (LG, ≥11 weeks, n=57). The relations among interval time and short-term clinical outcome and oncological outcome were analyzed.ResultsThe analysis found that basic information, clinical characteristics, and preoperative treatment between the two groups had no significant difference. There were no differences in operation time, estimated intraoperative blood loss and postoperative complications. The rate of sphincter preservation in the low and middle rectum was 66.7% in the short-interval group and 59.7% in the long-interval group (P=0.42). The incidence of anastomotic leak in the long-interval group was higher than that in the short-interval group (P=0.08). There was no significant difference in the recovery time of intestinal function and median duration of hospitalization between the two groups. The pathological complete remission rate was 17.07%. Multivariate analysis showed interval time had no influence on pathological complete remission. There was no significant difference in 3-year overall survival and 3-year disease-free survival between the two groups. The risk of recurrence and metastasis in patients with positive lymph nodes was higher than those with negative lymph nodes (P<0.05), HR=4.812 (95% CI 2.4–9.648).ConclusionProlonging the interval time of operation to 11 weeks after neoadjuvant chemoradiotherapy for middle and low rectal cancer does not improve the pathologic complete remission, morbidity, and mortality. There was no significant effect on oncologic outcome after prolonging the operation interval. Therefore, it is safe to prolong the interval of operation to 11 weeks.

Comparative study of loop ileostomy vs loop transverse colostomy as a covering stoma after low anterior resection for rectal cancer

Background After low anterior resection for rectal cancer, construction of a stoma for coverage of anastomosis is sometimes mandatory. Although loop ileostomy may be easily constructed and easily closed, it may have some complications related to fluid and electrolyte imbalance, especially in comorbid vulnerable patients. Aim This study aims to compare loop ileostomy and loop transverse colostomy as a covering stoma technique after resection of middle and low rectal cancer. Patients and methods This double-blind prospective study was done in a single institute on 70 patients diagnosed as having primary middle and low rectal cancer who underwent low anterior resection and ultra-low anterior resection and covering stoma was decided. Cases underwent surgery between October 2016 and January 2019. Patients were allocated to group A (ileostomy group) and group B (colostomy group). Results A total of 33 patients were in group A (ileostomy group) and 37 patients were in group B (colostomy group). Significantly higher rates of stoma-related complications were encountered in the loop ileostomy group (75.6(%than in loop transverse colostomy group (43.2%). Peristomal dermatitis was the highest occurring complication. Moreover, significantly higher rates of stoma reversal-related complications were encountered in the loop ileostomy group (45.4(%than in loop transverse colostomy group (13.5%). Diarrhea was the highest occurring complication. Conclusion Regarding stoma-related complications and stoma reversal perioperative complications, loop transverse colostomy was significantly better than loop ileostomy.

Can rectal tube be used instead of ileostomy in patients undergoing rectal resection after neoadjuvant chemo-radiotherapy?

Aim: Neoadjuvant chemo-radiotherapy and total mesorectal excision have become the standard treatment for locally advanced middle and distal rectal cancers. These types of patients carry a serious risk of anastomosis leakage. While the commonly technique is diverting ileostomy; rectal tube placement, with lower morbidity, has also been used in recent years. The aim of this study was to compare the results of ileostomy and rectal tube administration following rectal resection after neoadjuvant therapy.Material and Methods: We retrospectively reviewed the data from 25 patients with rectal cancer who received neoadjuvant chemo-radiotherapy between 2013 and 2019. Patients were evaluated in two groups: ileostomy and rectal tube. Demographic data, operative findings, pathological results, and follow-up information were evaluated.Results: Twelve were in the rectal tube group and 13 were in the ileostomy group. There was no difference between the two groups in terms of tumor location in preoperative data. Patients with hepatic metastasis were found in the ileostomy group, while there were no such patients in the rectal tube group. The operation time (452±128 vs. 295±102 min, p=0.002) and blood loss (485±264 vs 105±80 ml, p=0.0001) were higher in the ileostomy group. The intraoperative complications of the patients were similar in the two groups, whereas the postoperative complications were higher in the ileostomy group (69%-25%, p=0.04). The mean follow-up period was 23.2±18.5 months. The total complication rate due to ileostomy was 20% and the stomata of 15% of the patients were not closed. The cosmetic scores of the patients were better in the rectal tube group (9.8±0.3 vs. 6.3±1.7, p=0.0001). Conclusion: The results of the rectal tube technique were not worse than those of the ileostomy technique in rectal cancers receiving neoadjuvant therapy and this technique may be preferred in appropriate cases.

The individualized strategy for lateral pelvic lymph node dissection in advanced rectal cancer

Recently, with the development and widespread application of total mesorectal excision and neoadjuvant chemoradiotherapy, the long-term overall survival and disease-free survival of patients with middle & low rectal cancer have been greatly improved. Moreover, there are also researches in minimally invasive techniques, such as laparoscopy and robotic surgical system in the radical rectal surgery, as well as the combination of tumor molecular targeting markers and gene sequencing technology. Nowadays, the treatment of rectal cancer has entered a new era of individualized precise medicine. However, there are still some controversies in lateral lymph node dissection. The criteria of diagnosis and treatment, neoadjuvant therapy, indications of lateral lymph node dissection, the area of dissection and neuroprotection are still unsatisfactory. It is necessary to explore the personalized treatment strategies of lateral lymph node dissection in the precise medical era.

TransAnal Total Mesorectal Excision (TaTME) in Peru: Case series

IntroductionDescribe and demonstrate the feasibility and safety of TaTME in short term outcomes in the Instituto Nacional de Enfermedades Neoplásicas (INEN) in Peru. Materials and methodsCase series with retrospective and prospective data collection of patients with middle and inferior rectal cancer who underwent TaTME between January 2015 and March 2020. Patients and tumor characteristics, operative details, postoperative complications and pathological results were analyzed. ResultsNineteen patients were included. The median age was 56 years old (range 40–69). Ten were female. The median distance from the anal verge was 4 cm (range 3–6) and 17 cases were located in the inferior rectum. Eleven patients with clinical stage III. Thirteen (68.4%) patients received neoadjuvant treatment. There was no conversion to open surgery reported. Ten (52.6%) cases had intersphincteric resection and 18 (94.7%) had primary coloanal anastomosis, 13 (72.2%) of them with hand-sewn. All patients had a diversion with ileostomy. The median operative time was 330 min (range 270–480). Median postoperative hospital stay of 5 days (range 3–18). The overall rate of postoperative complication was 21.1%, two cases (10.5%) had anastomotic leakage and mortality was present in one (5.3%) patient. 94.5% had an optimal TME specimen, only one case (5.3%) had positive circumferential resection margin and positive distal margin. The median tumor size in the specimen was 4 cm (range 2–11) and nine (47.4%) patients had ypT3 on pathology. ConclusionTaTME is a safe and feasible technique with good pathological results.