Principles Of Total Mesorectal Excision Research Articles

The prevention of rectovaginal fistula after rectal cancer surgery by packing with laparoscopic dislocated fat flap containing ovarian vascular pedicle anterior to the anastomotic stoma: a parallel group randomized controlled trial protocol

BackgroundRectovaginal fistula (RVF) is an abnormal channel formed by epithelial tissue between the anterior wall of the rectum and the posterior wall of the vagina, which manifests as vaginal gassing and defecation. It is one of the common complications of female pelvic surgeries. With the increased number of proctectomies for rectal cancer, the number of postoperative rectovaginal fistulas also increases. Once RVF occurs, the failure rate is still high with various treatments available. RVF causes great suffering to women and is still a major problem in treatment. Therefore, it is significant for female rectal cancer patients to prevent RVF after rectal cancer surgery. In this study, we introduce a new method to prevent RVF during rectal cancer radical operation.MethodsIn this randomized controlled trial (RCT), all operations are performed according to the principle of total mesorectal excision (TME) radical resection in rectal cancer surgery. All eligible participants will be divided into two groups: the experimental group and the control group. Experimental group: the anterior rectal wall of about 1 cm distal to the anastomosis was dislocated. Before the anastomosis of the rectal end, a fat flap (usually left side) containing the ovarian vascular pedicle was dislocated, measured by 10–15 cm in length and 2 cm in width. The fat flap containing the ovarian vascular pedicle was packed and fixed anterior to the anastomotic stoma with fibrin glue. Control group: surgery will be carried out in accordance with the TME principle. Participants will be compared on several variables, including the incidence of RVF after operation (primary outcomes), the occurrence time of postoperative RVF, the occurrence time of RVF after stoma closure, and other postoperative complications, such as anastomotic leakage, chylous leakage, and intestinal obstruction (secondary outcomes). The follow-up data collection will be conducted according to the follow-up time point, and the baseline data will also be collected for follow-up analysis. By comparing the incidence of rectovaginal leakage between the experimental group and the control group, we aim to explore the feasibility of this method for the prevention of postoperative RVF.DiscussionThis RCT will explore the feasibility of packing with a laparoscopic dislocated fat flap containing an ovarian vascular pedicle anterior to the anastomotic stoma after rectal cancer surgery to prevent RVF.Trial registrationChinese Clinical Trial Registry (ChiCTR) registration ChiCTR2000031449. Registered on June 26, 2019. All items of the WHO Trial registration data set can be found within the protocol.

Methylene blue can increase the number of lymph nodes harvested in colorectal cancer: a meta-analysis.

The lymph node (LN) status plays an important role in colorectal cancer (CRC), which depends on adequate LN harvest. In some studies, methylene blue has been used to increase the number of LNs harvested in vitro. The purpose was to evaluate the effect of methylene blue staining on LN harvest during radical resection of CRC. The Cochrane Library, MEDLINE, Embase, PubMed, and Web of Science were searched from the dates of inception until 15 October 2022. Studies were included if they were randomized controlled trials or nonrandomized controlled trials for radical resection of rectal cancer according to the principle of total mesorectal excision that compared the use of methylene blue with blank control in LN harvest. The primary outcomes were the number of LNs harvested and the incidence of fewer than 12 LNs harvested. Of 328 articles found, a meta-analysis was conducted of 15 studies (2 randomized controlled trials and 13 non-randomized controlled trials) composed of 3104 patients. Meta-analysis showed that methylene blue could not only significantly increase the number of LNs harvested in CRC specimens (stained group 28.23 vs unstained group 16.15; weighted mean difference 12.08; 95% CI, 8.03-16.12; p < 0.001; I2 = 95%), but also reduce the incidence of fewer than 12 LNs harvested (methylene blue-stained group 7.91% vs unstained group 30.90%; OR 0.12; 95% CI, 0.05-0.26; p < 0.001; I2 = 78%). Methylene blue can increase the number of LNs harvested in CRC, reduce the incidence of fewer than 12 LNs harvested, and ensure the accuracy of LN staging.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision.

the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial

Robotic surgery for rectal cancer is gaining popularity, but evidence on long-term oncological outcomes is scarce. We aimed to compare surgical quality and long-term oncological outcomes of robotic and conventional laparoscopic surgery in patients with middle and low rectal cancer. Here we report the short-term outcomes of this trial. This multicentre, randomised, controlled, superiority trial was done at 11 hospitals in eight provinces of China. Eligible patients were aged 18-80 years with middle (>5 to 10 cm from the anal verge) or low (≤5 cm from the anal verge) rectal adenocarcinoma, cT1-T3 N0-N1 or ycT1-T3 Nx, and no evidence of distant metastasis. Central randomisation was done by use of an online system and was stratified according to participating centre, sex, BMI, tumour location, and preoperative chemoradiotherapy. Patients were randomly assigned at a 1:1 ratio to receive robotic or conventional laparoscopic surgery. All surgical procedures complied with the principles of total mesorectal excision or partial mesorectal excision (for tumours located higher in the rectum). Lymph nodes at the origin of the inferior mesenteric artery were dissected. In the robotic group, the excision procedures and dissection of lymph nodes were done by use of robotic techniques. Neither investigators nor patients were masked to the treatment allocation but the assessment of pathological outcomes was masked to the treatment allocation. The primary endpoint was 3-year locoregional recurrence rate, but the data for this endpoint are not yet mature. Secondary short-term endpoints are reported in this article, including two key secondary endpoints: circumferential resection margin positivity and 30-day postoperative complications (Clavien-Dindo classification grade II or higher). The outcomes were analysed according in a modified intention-to-treat population (according to the original assigned groups and excluding patients who did not undergo surgery or no longer met inclusion criteria after randomisation). This trial was registered with ClinicalTrials.gov, number NCT02817126. Study recruitment has completed, and the follow-up is ongoing. Between July 17, 2016, and Dec 21, 2020, 1742 patients were assessed for eligibility. 502 patients were excluded, and 1240 patients were enrolled and randomly assigned to receive either robotic surgery (620 patients) or laparoscopic surgery (620 patients). 69 patients were excluded (34 in the robotic surgery group and 35 in the laparoscopic surgery group). 1171 patients were included in the modified intention-to-treat analysis (586 in the robotic group and 585 in the laparoscopic group). Six patients in the robotic surgery group received laparoscopic surgery and seven patients in the laparoscopic surgery group received robotic surgery. 22 (4·0%) of 547 patients in the robotic group had a positive circumferential resection margin as did 39 (7·2%) of 543 patients in the laparoscopic group (difference -3·2 percentage points [95% CI -6·0 to -0·4]; p=0·023). 95 (16·2%) of patients in the robotic group had at least one postoperative complication (Clavien-Dindo grade II or higher) within 30 days after surgery, as did 135 (23·1%) of 585 patients in the laparoscopic group (difference -6·9 percentage points [-11·4 to -2·3]; p=0·003). More patients in the robotic group had a macroscopic complete resection than in the laparoscopic group (559 [95·4%] of 586 patients vs 537 [91·8%] of 585 patients, difference 3·6 percentage points [0·8 to 6·5]). Patients in the robotic group had better postoperative gastrointestinal recovery, shorter postoperative hospital stay (median 7·0 days [IQR 7·0 to 11·0] vs 8·0 days [7·0 to 12·0], difference -1·0 [95% CI -1·0 to 0·0]; p=0·0001), fewer abdominoperineal resections (99 [16·9%] of 586 patients vs 133 [22·7%] of 585 patients, difference -5·8 percentage points [-10·4 to -1·3]), fewer conversions to open surgery (10 [1·7%] of 586 patients vs 23 [3·9%] of 585 patients, difference -2·2 percentage points [-4·3 to -0·4]; p=0·021), less estimated blood loss (median 40·0 mL [IQR 30·0 to 100·0] vs 50·0 mL [40·0 to 100·0], difference -10·0 [-20·0 to -10·0]; p<0·0001), and fewer intraoperative complications (32 [5·5%] of 586 patients vs 51 [8·7%] of 585 patients; difference -3·3 percentage points [-6·3 to -0·3]; p=0·030) than patients in the laparoscopic group. Secondary short-term outcomes suggest that for middle and low rectal cancer, robotic surgery resulted in better oncological quality of resection than conventional laparoscopic surgery, with less surgical trauma, and better postoperative recovery. Shenkang Hospital Development Center, Shanghai Municipal Health Commission (Shanghai, China), and Zhongshan Hospital Fudan University (Shanghai, China).

Is Laparoscopic Complete Mesocolic Excision and Central Vascular Ligation Really Necessary for All Patients With Right-Sided Colon Cancer?

Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.

Pelvic membrane anatomy and surgery with network preservation of autonomic nervous system for rectal cancer

The principle of total mesorectal excision (TME) standardizes the resection range and surgical dissection plane in radical rectal cancer surgery, reduces the local recurrence rate and improves the long-term survival. TME is the "gold standard" in radical rectal cancer surgery. However, with the progress of laparoscopic surgical instruments and techniques in recent years, further understanding of pelvic membrane anatomy and autonomic nervous system has been gained, which makes the surgical plane of TME more accurate and the autonomic nervous system better preserved. According to anatomical discovery and histological confirmation, there is a fascia between the mesorectal fascia and pelvic parietal fascia, called pre-hypogastric nerve sheath, in which autonomic nervous system courses, including the superior hypogastric plexus, left and right hypogastric nerves, pelvic plexus and the neurovascular bundles, from the abdominal to the pelvic cavity behind the mesorectal fascia. It fuses with the end of the mesorectum at the superior border of musculi puborectalis, and goes around the mesorectum to join with Denonvillier fascia. On the basis of anatomical studies and empirical anatomical observations, we put forward the concept of network preservation of the autonomic nervous system: the main trunk as well as the nerve branches of the pelvic autonomic nervous system and accompanying blood vessels should be preserved to ensure the integrity of the nerve reflex arc. The concept allows the radical resection of rectal cancer to follow the principle of TME, and meanwhile, protect patient's urination function and sexual function to the greatest extent, improving the quality of life of patients after surgery.

Understanding the Anatomy of the Denonvilliers Fascia: Review Article

AbstractThe postoperative outcome of rectal cancer has been improved after the introduction of the principles of total mesorectal excision (TME). Total mesorectal excision includes resection of the diseased rectum and mesorectum with non-violated mesorectal fascia (en bloc resection). Dissection along the mesorectal fascia through the principle of the “holy plane” minimizes injury of the autonomic nerves and increases the chance of preserving them. It is important to stick to the TME principle to avoid perforating the tumor; violating the mesorectal fascia, thus resulting in positive circumferential resection margin (CRM); or causing injury to the autonomic nerves, especially if the tumor is located anteriorly. Therefore, identifying the anterior plane of dissection during TME is important because it is related with the autonomic nerves (Denonvilliers fascia). Although there are many articles about the Denonvilliers fascia (DVF) or the anterior dissection plane, unfortunately, there is no consensus on its embryological origin, histology, and gross anatomy. In the present review article, I aim to delineate and describe the anatomy of the DVF in more details based on a review of the literature, in order to provide insight for colorectal surgeons to better understand this anatomical feature and to provide the best care to their patients.

Minimally invasive complete mesocolic excision and central vascular ligation (CME/CVL) for right colon cancer.

Total mesorectal excision (TME) is the standard of care in rectal cancer surgery. Complete mesocolic excision and central vascular ligation (CME and CVL) are surgical concepts that are extrapolated from the principles of TME. Increasingly adopted by surgical units worldwide, laparoscopic CME/CVL for right sided colon cancer is a challenging procedure that requires meticulous dissection by the surgeon and detailed knowledge of the colonic vascular anatomy. This review article addresses the main issues pertaining to this surgical technique and also discusses steps on how to perform this operation safely.

Total mesorectal excision – 40 years of standard of rectal cancer surgery

Total mesorectal excision (TME) was first described 40 years ago by Richard Heald. The purpose of this article is to point out importance of this surgical procedure. Starting from first attempts to surgically cure rectal carcinoma in the nineteenth century through Miles’ operation at the beginning of the twentieth century results were not satisfactory due to high number of local recurrences after resections for rectal cancer. Progress in surgical technique and knowledge of anatomy and embryology of the rectum led to development of TME. Principle of TME is surprisingly simple: removal of the rectum with complete embryonic space containing lymph nodes which are site of primary dissemination of the disease. Main advantages and drawbacks of TME as well as focus on newer procedures developed from the concept of TME are presented in the form of a review.

What does robotic right colectomy add to its laparoscopic counterpart?

The right colectomy is commonly performed for the malignant lesions of the ascending colon and the hepatic flexure. Many surgical approaches have been proposed to treat right-sided tumors; of those laparoscopic surgery (LS) has gained a worldwide acceptance by decreasing the surgical trauma compared to open technique. However, LS has some limitations (i.e., rigid instrumentation) and the surgical community sought to develop new minimally invasive techniques to aim the weaknesses of the laparoscopy. Robotic surgery has emerged in the early 2000s, which quickly gained popularity thanks to its endo-wristed instruments and increased dexterity. The advantages of the robotic surgery—especially on the right colectomy frontier, are more likely to be pronounced with the implementation of complete mesocolic excision (CME) technique, which follows the same principles of total mesorectal excision. Furthermore, robotic surgery may ease and promote intracorporeal anastomosis which is challenging to perform with the laparoscopic approach. Despite its advantages, prolonged operative time and increased hospital costs are the main drawbacks for the robotic surgery. In this review, we aimed to discuss the role of robotic surgery on right colectomy in light of the most recent literature.

Analysis on the technical characteristics and clinical efficacy of robotic-assisted intersphincteric resection for patients with low rectal cancer

Objective: To explore the technical characteristics and short-term clinical efficacy of robotic-assisted intersphincteric resection (ISR) for patients with low rectal cancer. Methods: A retrospective cohort study was used. Inclusion criteria: (1) rigid colonoscopy showed lower margin of the tumor ≤5 cm from the anal verge; (2) preoperative rectal MRI or endorectal ultrasound revealed staging T1-2, or T3 patients receiving concurrent chemoradiotherapy; (3) patients less than 70 years old with good function of anal sphincter before surgery; (4) no synchronous multiple primary carcinoma, and no distant metastasis; (5) the method of operation was agreed by the patient. Exclusion criteria: (1) T4 stage tumors; (2) sphincter dysfunction before operation; (3) recurrent tumors; (4) lower edge of tumors beyond the dentate line; (5) death due to non-rectal cancer during follow-up and unsatisfactory follow-up data. The clinical data of 21 patients with low rectal cancer meeting inclusion criteria undergoing robotic-assisted ISR at our department from January 2015 to June 2018 were collected. Parameters during and after operation were observed. Anorectal manometry was performed at 3, 6, and 12 months after the operation, and anal function was evaluated at 3, 6, and 12 months after the closure of the stoma by Kirwan classification and Wexner fecal incontinence score. The key steps of the operation are as follows: according to the principle of total mesorectal excision, the robot continued to enter into the levator ani hiatusdistally, and dissectin the sphincter space; according to the scope of sphincter resection, ISRwas divided into partial ISR, subtotal ISR, and total ISR; subtotal and total ISR usually needed to be combined with transanal pathway. The reconstruction of digestive tract was performed by double stapler anastomosis under laparoscope orhand-sewnanastomosis under direct vision, and preventive ileostomy was completed in the right lower abdomen. Results: Of 21 patients, 13 were male and 8 were female with mean age of (57.5±16.3) years. All the patients successfully completed the operation without conversion to laparotomy. Fourteen cases (66.7%) adopted partial ISR through complete transabdominal approach, 6 cases (28.6%) adopted the subtotal ISR through combined transabdominal and transanal approachs, and 1 case (4.8%) adopted the total ISR through the combined transabdominal and transanal approachs. The total operation time was (213.1±56.3) minutes, including (27.3±5.4) minutes for mechanical arm installation and (175.7±51.6) minutes for robotic operation. The amount of intraoperative hemorrhage was (62.8±23.2) ml, and no blood transfusion was performed in any patient. All patients underwent prophylactic ileostomy, and the stoma was closed 3-6 months after the operation. Except one case of anastomotic leakage, all other stomas were closed successfully. The postoperative hospitalization time was (7.6±2.2) days, and time to fluid intake was (3.3±0.9) days. One case of anastomotic leakage, one case of anastomotic stenosis, one case of inflammatory external hemorrhoids and one case of urinary retention occurred after surgery,and all of them were cured by conservative treatment. The mean diameter of tumors was (2.9±1.2) cm, and the number of harvested lymph node was 12.8 ± 3.3. In the whole group, the circumcision margin was negative, the proximal margin was (12.2 ± 2.1) cm, the distal margin was (1.1 ± 0.4) with all negative, and the R0 resection rate was 100%. The results of anorectal manometry showed that the preoperative rest pressure, rectal maximum squeeze pressure, initial sensory volume and maximum tolerated volume were (45.19±8.46) mmHg, (128.18±18.80) mmHg, (44.33±10.11) ml and (119.00±19.28) ml, respectively;these parameters reduced significantly 3 months after operation and they were (23.44±5.54) mmHg, (93.72±12.15) mmHg, (17.72±5.32) ml and (70.44±10.9) ml, respectively. The differences were statistically significant (all P<0.001). The resting pressure and the rectal maximum squeeze pressure returned to preoperative levels 12 months after operation, which were (39.33±6.64) mmHg and (120.58±16.47) mmHg, respectively (both P>0.05), while the initial sensory volume and the maximum tolerated volume failed to reach the preoperative state, which were (30.67±7.45) ml and (92.25±10.32) ml, respectively (both P<0.05). The patients were followed up for (22.1±10.6) months without local recurrence and distant metastasis. Eighteen patients were evaluated for anal function: Kirwan classification was grade I for 6 cases, grade II for 7 cases, grade III for 4 cases, and grade IV for 1 case; Wexner incontinence score was 8.6±0.8; 14 cases had good defecation control. Conclusion: The clinical efficacy of ISR with Da Vinci robot in the treatment of low rectal cancer is satisfactory.

Investigation on the integrity of mesorectal specimens of transanal total mesorectal excision

Total mesorectal excision (TME) has become the gold standard for mid-low rectal cancer surgery. However, for some patients with obesity and narrow pelvis, there are great challenges in both open and laparoscopic surgery. Transanal total mesorectal excision (taTME) uses a transanal approach, in " bottom-up" direction, which reduces the difficulty of distal mesorectal excision and may improve the quality of the TME specimen. The taTME provides a direct sight of the tumor and the distal resection margin is more precise. However, whether taTME can achieve complete total mesorectal excision, especially for mid-rectal cancer, is still controversial. This study compares the quality and integrity of mesorectum among open surgery, laparoscopic surgery, and taTME surgery according to TME principles and quality evaluation criteria of TME specimen. In conclusion, the integrity of mesorectum of taTME specimens for low-rectal cancer is good. But for the mid-rectal cancer, the integrity of mesorectum of taTME specimens and long-term efficacy are still controversial and need high-level evidence support.

Treatment of Patients With Early-Stage Colorectal Cancer: ASCO Resource-Stratified Guideline.

PURPOSETo provide resource-stratified, evidence-based recommendations on the treatment and follow-up of patients with early-stage colorectal cancer.METHODSASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus process with additional experts for one round of formal ratings.RESULTSExisting sets of guidelines from 12 guideline developers were identified and reviewed; adapted recommendations from six guidelines form the evidence base and provide evidence to inform the formal consensus process, which resulted in agreement of 75% or more on all recommendations.RECOMMENDATIONSFor nonmaximal settings, the recommended treatments for colon cancer stages nonobstructing, I-IIA: in basic and limited, open resection; in enhanced, adequately trained surgeons and laparoscopic or minimally invasive surgery, unless contraindicated. Treatments for IIB-IIC: in basic and limited, open en bloc resection following standard oncologic principles, if not possible, transfer to higher-level facility; in emergency, limit to life-saving procedures; in enhanced, laparoscopic en bloc resection, if not possible, then open. Treatments for obstructing, IIB-IIC: in basic, resection and/or diversion; in limited or enhanced, emergency surgical resection. Treatment for IIB-IIC with left-sided: in enhanced, may place colonic stent. Treatment for T4N0/T3N0 high-risk features or stage II high-risk obstructing: in enhanced, may offer adjuvant chemotherapy. Treatment for rectal cancer cT1N0 and cT2n0: in basic, limited, or enhanced, total mesorectal excision principles. Treatment for cT3n0: in basic and limited, total mesorectal excision, if not, diversion. Treatment for high-risk patients who did not receive neoadjuvant chemotherapy: in basic, limited, or enhanced, may offer adjuvant therapy. Treatment for resectable cT3N0 rectal cancer: in enhanced, base neoadjuvant chemotherapy on preoperative factors. For post-treatment surveillance, a combination of medical history, physical examination, carcinoembryonic antigen testing, imaging, and endoscopy is performed. Frequency depends on setting. Maximal setting recommendations are in the guideline. Additional information can be found at www.asco.org/resource-stratified-guidelines.NOTICEIt is the view of the American Society of Clinical Oncology that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guidelines are intended to complement but not replace local guidelines.

Can Endorectal Ultrasound, MRI, and Mucosa Integrity Accurately Predict the Complete Response for Mid-Low Rectal Cancer After Preoperative Chemoradiation? A Prospective Observational Study from a Single Medical Center.

Patients with locally advanced rectal cancer could be managed by a watch-and-wait approach if they achieve clinical complete response after preoperative chemoradiotherapy. Mucosal integrity, endorectal ultrasound, and rectal MRI are used to evaluate clinical complete response; however, the accuracy remains questionable. Clinical practice based on those assessment methods needs more data and discussion. The aim of this prospective study was to evaluate the accuracy of mucosal integrity, endorectal ultrasound, and rectal MRI to predict clinical complete response after chemoradiotherapy. Endorectal ultrasound and rectal MRI were undertaken 6 to 7 weeks after preoperative chemoradiation therapy. Patients then received radical surgery based on the principles of total mesorectal excision. Preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity, specificity, and accuracy of each evaluation method were calculated. The study was conducted at a single tertiary care center. Patients diagnosed with mid-low rectal cancer by biopsy between May 2014 and December 2016 were enrolled in this study. A total of 124 patients were enrolled in this study, and postoperative pathology revealed that 20 patients (16.13%) achieved complete response (ypT0N0). The sensitivity of mucosal integrity, endorectal ultrasound, and MRI to predict clinical complete response was 25%. The specificity of mucosal integrity, endorectal ultrasound, and MRI was 94.23%, 93.90%, and 93.27%. The combination of each 2 or all 3 methods did not improve accuracy. Regression analysis showed that none of these methods could predict postoperative ypT0. The sample size is small, and we did not focus on the follow-up data and cannot compare prognosis data with previous research studies. Both single-method and combined mucosal integrity, endorectal ultrasound, and rectal MRI have poor correlation with postoperative pathologic examination. A watch-and-wait approach based on these methods might not be a proper strategy compared with radical surgery after neoadjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A693.

Effects of three-dimensional and two-dimensional laparoscopic surgeries for rectal cancer after neoadjuvant chemoradiation therapy

Objective To compare the clinical effects of three-dimensional (3D) and two-dimensional (2D) laparoscopic surgeries for rectal cancer (RC) after neoadjuvant chemoradiation therapy (nCRT). Methods The retrospective cohort study was conducted. The clinicopathological data of 126 patients with RC who received laparoscopic surgery after nCRT in the Liaoning Cancer Hospital from January 2013 to January 2014 were collected. Of 126 patients, 63 undergoing 3D laparoscopic surgery and 63 undergoing 2D laparoscopic surgery were respectively allocated into the 3D and 2D groups. Surgery was performed by the same doctors′ team. Patients received surgery at 6-8 weeks after nCRT, and surgery followed the principle of total mesorectal excision. Observation indicators: (1) intra- and post-operative situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect local tumor recurrence and patients′ survival up to January 2017. Patients received reexaminations once every 3 months within 1 year postoperatively and once every 6 months after 2-3 years postoperatively. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Comparisons of count data were analyzed using the chi-square test. Comparison of ordinal data was done by the nonparametric test. Survival curve was drawn using the Kaplan-Meier method. Survival was analyzed using the Log-rank test. Results (1) Intra- and post-operative situations: all the patients underwent successful laparoscopic surgery for RC, without conversion to open surgery and perioperative death. Operation time, volume of intraoperative blood loss, time to anal exsufflation and number of patients with postoperative urinary dysfunction were (125±10)minutes, (54±23)mL, (44±5)hours, 0 in the 3D group and (137±12)minutes, (62±20)mL, (46±5)hours, 5 in the 2D group, respectively, with statistically significant differences between the 2 groups (t=5.777, 2.038, 2.575, χ2=7.138, P 0.05). Two and 4 patients with anastomotic leakage in the 3D and 2D groups received defunctioning stoma, and finally anastomotic leakage healed, without anastomotic stenosis. Of 5 patients with urinary dysfunction in the 2D group, 4 received indwelling catheter for 3 weeks and then can micturate autonomously after indwelling catheter removal, 1 received indwelling catheter for 3 months and then can micturate autonomously after indwelling catheter removal, without suprapubic cystostomy. (2) Postoperative pathological examination: 0 and 4 patients in the 3D and 2D groups had positive circumferential margin, with a statistically significant difference (χ2=5.676, P 0.05). Number of patients with stage Ⅱ and Ⅲ of postoperative pathological staging were 30, 33 in the 3D group and 32, 31 in the 2D group, respectively, with no statistically significant difference between the 2 groups (χ2=0.127, P>0.05). (3) Follow-up and survival situations: 126 patients were followed up for 36.0-48.0 months, with a median time of 39.5 months. During the follow-up, 0 and 3 patients in the 3D and 2D groups were complicated with local tumor recurrence, with a statistically significant difference between the 2 groups (χ2=4.232, P 0.05). One- and 3-year disease-free survival rates were 92.7%, 77.8% in the 3D group and 90.5%, 73.0% in the 2D group, respectively, with no statistically significant difference between the 2 groups (χ2=0.421, P>0.05). Conclusion Compared with 2D laparoscopic surgery, 3D laparoscopic surgery for RC after nCRT is safe and feasible, it can also shorten operation time, reduce intraoperative bleeding, alleviate the influence of intestinal peristalsis function, protect pelvic nerves better and improve operation quality. Key words: Rectal neoplasms; Neoadjuvant chemoradiation therapy; Radical resection; Laparoscopy; Three-dimensional technology

Effect analysis of three-dimensional and two-dimensional imaging systems in laparoscopic radical resection of rectal cancer

Objective To compare the clinical effect of three-dimensional (3D) and two-dimensional (2D) imaging systems in laparoscopic radical resection of rectal cancer. Methods The retrospective cohort study was adopted. The clinical data of the 97 patients who underwent laparoscopic radical resection of rectal cancer at the Xinmin Branch of the China-Japan Union Hospital of Jilin University between May 2012 and December 2014 were collected. Of 97 patients, 47 undergoing 3D laparoscopic radical resection of rectal cancer were allocated into the 3D group and 50 undergoing 2D laparoscopic radical resection of rectal cancer were allocated into the 2D group. The operation followed strictly tumor-free and total mesorectal excision principles. Observation indicators included: (1) surgical situations: operation time, time of deep lymph nodes dissected, volume of intraoperative blood loss, bleeding volume of obturator lymph nodes dissected, number of lymph nodes dissected, postoperative complications and duration of hospital stay. (2) Follow-up situations: follow-up using outpatient examination and telephone interview was performed to detect the survival of patients and tumor recurrence and metastasis up to December 2015. Measurement data with normal distribution were presented as ±s and comparison between groups was analyzed using the t test. Count data were analyzed using the chi-square test. Results (1) Surgical situations: all the patients underwent successful laparoscopic radical resection of rectal cancer, without conversion to open surgery. Operation time, time of deep lymph nodes dissected, volume of intraoperative blood loss, bleeding volume of obturator lymph nodes dissected, number of lymph nodes dissected and duration of postoperative hospital stay were (134.6±18.5)minutes, (21.2±2.7)minutes, (65±20)mL, (16±3)mL, 23.6±3.5, (8.2±2.3)days in the 3D group and (157.4±17.8)minutes, (25.2±2.5)minutes, (89±27)mL, (23±5)mL, 20.5±2.8, (9.4±2.1)days in the 2D group, respectively, with statistically significant differences between the 2 groups (t=2.999, 3.739, 2.327, 4.221, 2.337, 1.274, P 0.05). (2) Follow-up situations: 75 of 97 patients were followed up for 12-36 months with a median time of 24 months, including 35 in the 3D group and 40 in the 2D group, and they were tumor-free survival. Conclusion Compared with 2D laparoscopic radical resection of rectal cancer, 3D laparoscopic radical resection of rectal cancer can shorten the operation time and reduce tissue damage and intraoperative blood loss, and it is beneficial to deep lymph node dissection. Key words: Rectal neoplasms; Radical resection; Laparoscopy; Three-dimension

Efficacy and safety of preoperative neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer : a clinical analysis of 291 patients

Objective To evaluate the efficacy and safety of neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer (LARC) before surgery. Methods A total of 291 LARC patients who received preoperative chemoradiotherapy and surgery with or without postoperative adjuvant chemotherapy from March 2003 to May 2012 were included in the study. The radiotherapy delivered was two-dimensional conformal radiotherapy (2DRT) and three-dimensional conformal radiotherapy (3 DRT) , and the total dose ranged from 45 to 50 Gy in 23-25 fractions. All the patients received preoperative chemotherapy including FOLFOX6, XELOX, and Xeloda for 2- 4 cycles. Surgery following the principle of total mesorectal excision was performed 3-8 weeks after radiotherapy. Postoperative adjuvant chemotherapy was delivered to 134 patients. The overall survival (OS) , disease-free survival (DFS , relapse-free survival(RFS) , and distant metastasis-free survival (DMFS) were determined using the Kaplan-Meier method, and survival difference analysis and univariate prognostic analysis were performed using the log-rank test. Multivariate prognostic analysis was performed using the Cox proportional hazard model. Results All the patients completed the preoperative neoadjuvant chemoradiotherapy and surgery. The rate of radical resection(R0) was 98.9%, and the sphincter preservation rate was 53.6%. The downstaging rates in tumor (T)stage, node (N) stage, and clinical stage were 73.1%, 83.6%, and 79.4%, respectively. Pathologic complete response rate was 26.8%. Grade 3 adverse hematologic reactions, grade 3 diarrhea, and grade 3radiodermatitis were observed in 7.9%, 7.2% and 2.7% of total patients, respectively. Postoperative perineal pain and delayed wound healing were reported in 12.3% and 8.2% of total patients, respectively. The follow-up rate was 94.5% and the 5-year sample size was 95 patients. The 5-year OS, DFS, RFS, and DMFS were 76.6%, 72.1%, 88.8%, and 79.7%, respectively. The 5-year local recurrence rate and distant metastasis rate were 7.5% and 15.8%, respectively. Multivariate analysis revealed that the postoperative pathological staging was a prognostic influencing factor. Conclusions Preoperative neoadjuvant chemoradiotherapy increases the R0 and sphincter preservation rates, and results in significant tumor downstaging. Treatment-related adverse reactions are moderate and perioperative complications are not increased. The local recurrence rate is low and long-term survival rate is increased. Clinical application of preoperative neoadjuvant chemoradiotherapy as a standard treatment regimen for LARC is highly recommended. Key words: Rectal neoplasms, locally advanced/neoadjuvant chemoradiotherapy; Rectal neoplasms, locally advanced/surgery; Prognosis

Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study

Application of the principles of total mesorectal excision to colon cancer by undertaking complete mesocolic excision (CME) has been proposed to improve oncological outcomes. We aimed to investigate whether implementation of CME improved disease-free survival compared with conventional colon resection. Data for all patients who underwent elective resection for Union for International Cancer Control (UICC) stage I-III colon adenocarcinomas in the Capital Region of Denmark between June 1, 2008, and Dec 31, 2011, were retrieved for this population-based study. The CME group consisted of patients who underwent CME surgery in a centre validated to perform such surgery; the control group consisted of patients undergoing conventional colon resection in three other hospitals. Data were collected from the Danish Colorectal Cancer Group (DCCG) database and medical charts. Patients were excluded if they had stage IV disease, metachronous colorectal cancer, rectal cancer (≤ 15 cm from anal verge) in the absence of synchronous colon adenocarcinoma, tumour of the appendix, or R2 resections. Survival data were collected on Nov 13, 2014, from the DCCG database, which is continuously updated by the National Central Office of Civil Registration. The CME group consisted of 364 patients and the non-CME group consisted of 1031 patients. For all patients, 4-year disease-free survival was 85.8% (95% CI 81.4-90.1) after CME and 75.9% (72.2-79.7) after non-CME surgery (log-rank p=0.0010). 4-year disease-free survival for patients with UICC stage I disease in the CME group was 100% compared with 89.8% (83.1-96.6) in the non-CME group (log-rank p=0.046). For patients with UICC stage II disease, 4-year disease-free survival was 91.9% (95% CI 87.2-96.6) in the CME group compared with 77.9% (71.6-84.1) in the non-CME group (log-rank p=0.0033), and for patients with UICC stage III disease, it was 73.5% (63.6-83.5) in the CME group compared with 67.5% (61.8-73.2) in the non-CME group (log-rank p=0.13). Multivariable Cox regression showed that CME surgery was a significant, independent predictive factor for higher disease-free survival for all patients (hazard ratio 0.59, 95% CI 0.42-0.83), and also for patients with UICC stage II (0.44, 0.23-0.86) and stage III disease (0.64, 0.42-1.00). After propensity score matching, disease-free survival was significantly higher after CME, irrespective of UICC stage, with 4-year disease-free survival of 85.8% (95% CI 81.4-90.1) after CME and 73.4% (66.2-80.6) after non-CME (log-rank p=0·0014). Our data indicate that CME surgery is associated with better disease-free survival than is conventional colon cancer resection for patients with stage I-III colon adenocarcinoma. Implementation of CME surgery might improve outcomes for patients with colon cancer. Tvergaards Fund and Edgar and Hustru Gilberte Schnohrs Fund.

Product Analysis and Initial Reliability Testing of the Total Mesorectal Excision-Quality Assessment Instrument

Product analysis of rectal cancer resection specimens before specimen fixation may provide an immediate and relevant evaluation of surgical performance. We tested the interrater reliability (IRR) of a product analysis tool called the Total Mesorectal Excision-Quality Assessment Instrument (TME-QA). Participants included two gold standard raters, five pathology assistants, and eight pathologists. Domains of the TME-QA reflect total mesorectal excision principles including: (1) completeness of mesorectal margin; (2) completeness of mesorectum; (3) coning of distal mesorectum; (4) physical defects; and (5) overall specimen quality. Specimens were scored independently. We used the generalizability theory to assess the tool's internal consistency and IRR. There were 39 specimens and 120 ratings. Mean overall specimen quality scores for the gold standard raters, pathologists, and assistants were 4.43, 4.43, and 4.50, respectively (p > 0.85). IRR for the first nine items was 0.68 for the full sample, 0.62 for assistants alone, 0.63 for pathologists alone, and 0.74 for gold standard raters alone. IRR for the item overall specimen quality was 0.67 for the full sample, 0.45 for assistants, 0.80 for pathologists, and 0.86 for gold standard raters. IRR increased for all groups when scores were averaged across two raters. Assessment of surgical specimens using the TME-QA may provide rapid and relevant feedback to surgeons about their technical performance. Our results show good internal consistency and IRR when the TME-QA is used by pathologists. However, for pathology assistants, multiple ratings with the averaging of scores may be needed.

Clinical study of laparoscopic rectal surgery without abdominal scar

To assess the feasibility and safety of laparoscopic rectal surgery without abdominal scar. A total of 23 patients of rectal cancer were operated by laparoscopy with the assistance of PPH (procedure for prolapse and hemorrhoids) anal expander and TEM (transanal endoscopic microsurgery) outer-shell according to the principle of TME (total mesorectal excision). All operations were successfully accomplished laparoscopically. There was no conversion into an open procedure. The average operative duration was 129 (105 - 211) minutes. The intra-operative blood loss volume was 152 (85 - 420) ml. No immediate or delayed injury of urinary duct and other intra-operative severe complications, such as massive hemorrhage of presacral venous plexus, occurred. There was no pelvic infection or anastomotic stoma fistula during the post-operative period. The average follow-up period was 13.4 months. Neither anastomotic stoma recurrence nor Trocar implantation occurred. The laparoscopic technique of hybrid NOTES (Natural Orifice Transluminal Endoscopic Surgery), plus PPH/TEM is both feasible and convenient for selective rectal cancer surgery. There is no need for extra abdominal incision. It is recommended for laparoscopic rectal surgery.