Rate Of Circumferential Margin Involvement Research Articles

Circumferential resection margin rates in esophageal cancer resection- oncological equivalency and comparable clinical outcomes between open versus minimally invasive techniques: A retrospective cohort study.

Radical surgery for esophageal cancer requires macroscopic and microscopic clearance of all malignant tissue. A critical element of the procedure is achieving a negative circumferential margin (CRM) to minimize local recurrence. The utility of minimally invasive surgery poses challenges in replicating techniques developed in open surgery, particularly for hiatal dissection in esophago-gastrectomy. In this study, the technical approach and clinical and oncological outcomes for open and laparoscopic esophago-gastrectomy are described with particular reference to CRM involvement. This cohort study included all patients undergoing either open or laparoscopic esophago-gastrectomy between January 2004 to June 2022 in a single tertiary center. A standard surgical technique for hiatal dissection of the esophago-gastric junction developed in open surgery was adapted for a laparoscopic approach. Clinical parameters, length of stay (LOS), post-operative complications and mortality data were collected and analyzed by a Mann-Whitney U or Fisher's exact method. Overall 447 patients underwent an esophago-gastrectomy in the study with 219 open and 228 laparoscopic procedures. The CRM involvement was 18.8% in open surgery and 13.6% in laparoscopic surgery. The 90-day-mortality for open surgery was 4.1% compared with 2.2% for laparoscopic procedures. Median Intensive care unit (ITU), inpatient LOS and 30-day readmission rates were shorter for laparoscopic compared with open esophago-gastrectomy (ITU: 5 versus 8 days, P=0.0004; LOS: 14 versus 20 days, P=0.022; 30-day re-admission 7.46% versus 10.50%). Post-operative complication rates were comparable across both cohorts. The rates of starting adjuvant chemotherapy were 51.8% after open and 74.4% in laparoscopic esophago-gastrectomy. This study presents a standardized surgical approach to hiatal dissection for esophageal cancer. We present equivalence between open and laparoscopic esophago-gastrectomy in clinical, oncological and survival outcomes with similar rates of CRM involvement. We also observe a significantly shorter hospital length of stay with the minimally invasive approach.

Inframesocolic artery-first approach in laparoscopic ramps

Purpose: In 2003, Strasberg described the radical antegrade modular pancreatosplenectomy. This procedure is specifically designed for the surgical treatment of cancer of the body/tail of the pancreas. It primarily aims to achieve low rates of circumferential margin involvement and oncologically adequate lymphadenectomy. Recently, an adaptation of the surgical technique to the laparoscopic context has been described. This approach accesses the retroperitoneal plane as the first manoeuvre. This inframesenteric approach ensures oncologically adequate margins and allows to take full advantage of the vision and features of minimally invasive surgery. Method: A 52 year old female patient was diagnosed with body-tail junction pancreatic adenocarcinoma. CT scan revealed a focal lesion of approximately 19 mm in the pancreatic tail. The patient received 4 cycles of neoadjuvant chemotherapy with FOLFIRINOX regimen. Following, laparoscopic RAMPS was performed as follows: Five trocars were placed. After opening theomental bursa to rule out peritoneal disease, an inframesenteric approach of the SMA was performed. By means of a ligament of Treitz approach, the left renal vein and the left-superior aspect of the SMA were dissected; also, and dividing the SMV, retroperitoneal dissection was further dissected. This approach rules out tumor infiltration into the SMA and also allows the early determination of the posterior dissection plane. Then, extended lymphadenectomy is performed. After dividing the neck of the pancreas and splenic vein, the retroperitoenal space -previously developed- is entered. This facilitates the completion of the procedure thus ensuring a negative tangential margin. Results: Operation was completed without any intraoperative complication. Surgical time was 360 minutes. Blood loss was less than 50 mL. Patient was discharged on fourth postoperative day and no postoperative complications were observed. 17 lymph nodes were identified on the pathological report, none of them were affected by carcinoma. No vascular nor lymphatic invasion was documented. All resection margins were tumor-free. Conclusion: The inframesocolic artery-first approach in laparoscopic RAMPS is a feasible and safe procedure. It confirms resectability early in the procedure, ensures and facilitates tumor free-margins, may reduce blood loss and reproduce optimal oncological results.

Robotic surgery for rectal cancer as a platform to build on: review of current evidence.

Laparoscopy in colorectal surgery reduces the rate of postoperative complications, shortens the length of stay in hospital, and improves the quality of patient care. Despite these established benefits, the technical challenges of rectal resection for cancer have resulted in most operations being performed through open surgery in the USA. Moreover, controversy in the current literature questions the oncologic safety of a laparoscopic approach for rectal cancer. How then can surgeons innovate to overcome the technical challenges while preserving the critical oncological outcomes of high-quality rectal cancer surgery? Robotics may be a platform that allows us to overcome the technical challenges in the pelvis while maintaining both oncological outcomes and the benefits of a minimally invasive technique. Current evidence suggests that the quality of total mesorectal excision, the rates of circumferential margin involvement, and postoperative outcomes are comparable between robotic and laparoscopic surgery. While a robotic approach demonstrates lower conversion rates and reduced surgeon workload, the operative time is longer and initial costs are higher; however, time and future science will determine its true benefits. We review the current state of robotic surgery and its impact on rectal cancer surgery.

Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery. Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data. We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods. Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes. Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.

Surgical strategy for low rectal cancers

The two goals of surgery for lower rectal cancer surgery are to obtain clear "curative" margins and to limit post-surgical functional disorders. The question of whether or not to preserve the anal sphincter lies at the center of the therapeutic choice. Histologically, tumor-free distal and circumferential margins of>1mm allow a favorable oncologic outcome. Whether such margins can be obtained depends of TNM staging, tumor location, response to chemoradiotherapy and type of surgical procedure. The technique of intersphincteric resection relies on these narrow margins to spare the sphincter. This procedure provides satisfactory oncologic outcome with a rate of circumferential margin involvement ranging from 5% to 11%, while good continence is maintained in half of the patients. The extralevator abdominoperineal resection provides good oncologic results, however this procedure requires a permanent colostomy. A permanent colostomy alters several domains of quality of life when located at the classical abdominal site but not when brought out at the perineal site as a perineal colostomy.

Comparison of fecal continence and quality of life between intersphincteric resection and abdominoperineal resection plus perineal colostomy for ultra‐low rectal cancer

The only two procedures for surgical treatment of ultra-low rectal cancer without a permanent abdominal stoma are the intersphincteric resection (ISR) and the abdominoperineal resection (APR) plus a perineal pseudocontinent colostomy (PCC). This study compared functional results and quality of life following these two techniques. Between January 1995 and December 2011, 36 patients had undergone an ISR (n = 14) or a PPC (n = 22) for very low rectal cancer. The Cleveland Clinica Florida (Wexner) fecal incontinence questionnaire and the EORTC Quality of Life questionnaire QLQ-C30 and CR38 had been administered. There were no differences in gender, age, the interval between surgery and questionnaire responses, preoperative TNM staging, perioperative treatment, the laparoscopic approach and circumferential margin involvement rate between the groups. The ISR and PPC led to no difference in quality of life (Qol) and continence with a median Wexner score of respectively 11 and 10 (P = 0.403) and a fecal incontinence rate of 58.2% and 41% (P = 0.221). The incontinent patients had experienced worse social functioning and tended to have worse overall health. The patients who had undergone ISR had more defecation problems and evacuation difficulties. Qol and continence are similar between ISR and PPC.

P36. Low positive circumferential margins can be achieved by standard APR with careful MRI assessment and neo-adjuvant treatment

Aims: Recent moves towards wider resection of low rectal tumours using techniques such as ELAPe have been based on data reporting high rates of circumferential margin (CRM) involvement and inadvertent bowel perforation in standard abdomio-perineal resections (APR). This has been associated with worse outcome. We aimed to demonstrate the rate of CRM involvement in a small district general hospital to determine whether ELAPe should be adopted as our standard technique for low rectal tumours.

Favorable Pathologic and Long-Term Outcomes From the Conventional Approach to Abdominoperineal Resection

Suboptimal oncologic outcomes from abdominoperineal resection have been related to high rates of circumferential margin involvement. The extralevator approach has gained popularity as a means of reducing circumferential margin involvement, but it remains unknown whether comparable outcomes are achievable with a conventional approach to abdominoperineal resection. This study aimed to determine the rate of circumferential margin involvement, to identify factors predictive for a positive circumferential margin, and to relate these findings to long-term outcomes. This is a retrospective analysis of a prospective clinical database. This study was conducted at a single center, Mount Sinai Hospital, Toronto. Patients were included who underwent abdominoperineal resection for low rectal adenocarcinoma between 1997 and 2006. The main outcome measures included the rate of circumferential margin involvement, local recurrence, and disease-free survival. A total of 115 patients underwent abdominoperineal resection for primary adenocarcinoma of the rectum. A positive circumferential margin was demonstrated in 18 patients (15.7%). Intraoperative perforations occurred in 7 patients (6.1%). Tumors located anteriorly had a higher rate of circumferential margin involvement (31.6%) compared with lateral (13%), posterior (10%), and circumferential tumors (0%) (P = .024). This finding was reflected by a reduced median distance to the circumferential margin in anterior tumors. Curative resections (n = 108) were followed up for a median of 55.5 months. The 5-year local recurrence rate was 10.6% and the 5-year disease-free survival was 67.4%. Cox regression analysis revealed that circumferential margin involvement was an independent predictor for local recurrence; and T-category, N-category, and circumferential margin involvement for disease-free survival. This study was limited by its sample size and the number of outcome events. The conventional approach to abdominoperineal resection can produce oncologic outcomes comparable to the extralevator approach. However, the rate of circumferential margin involvement is higher than in restorative procedures and may be related to difficulties in obtaining adequate clearance in anterior tumors.

Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview

After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence. A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics. In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups. This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.

Pathologic study of circumferential margin involvement in middle and lower rectal cancer

To study the rule of circumferential margin involvement (CMI) in middle and low rectal cancer and improve its detection rate. Pathological large slices stained by HE method was combined with immunohistochemistry to study the CMI of 41 patients with middle and low rectal cancer. There were 20 female and 21 male patients, with an average age of 59.5 years (range, 33 to 77 years). The positive rate of CMI by HE staining was 21.9%. The CMI positive rates of CK20, CDX2 and MMP7 by immunohistochemistry staining was 29.3%, 31.7% and 26.8%, respectively. The positive rate of CMI was 36.6% when combined both HE and immunohistochemistry test, which was significantly higher than those in single methods (all P < 0.05). The positive rate of CMI in poorly differentiated tumor was significantly higher than that in moderately and well-differentiated tumor. The positive rate of CMI in the tumors with a distance of less than 5 cm between the anal verge and the lower tumor margin was significantly higher than that in tumors with the above-mentioned distances of greater than or equal to 5 cm (P < 0.05). According to MMP7 detection, the positive rate of CMI in the group without lymphatic metastasis was significantly lower than that in N1 and N2 group (all P < 0.05). There was no significant correlation between CMI and gender, age, tumor infiltration, lymphatic metastasis, general pathological types and operation methods (P > 0.05). The positive detection rate of CMI can be improved when combined large slices HE staining and immunohistochemistry. There is significant association between CMI and poorly differentiated tumor, lower location and positive lymphatic metastasis.

Management and imaging of low rectal carcinoma

Large variations in recurrence rates have been reported with the best results following total mesorectal excision (TME) surgery for low and middle rectal cancers. However, the low rectal cancers still have higher rates of local recurrence (up to 30%) whether operated by low anterior resection or abdominoperineal excision (APE) due to high rates of circumferential margin involvement. The treatment of choice for low rectal cancers that encroach upon the potential circumferential resection margin is surgery combined with preoperative neoadjuvant treatment. Preoperative chemotherapy combined with long-term radiotherapy reduces recurrence rates and preoperative loco-regional staging can help to select the patients more likely to benefit from neo-adjuvant therapy. Surface coil MRI is the most promising modality for patient selection, which can provide good views of the circumferential resection margin especially the presence or absence of tumour encroaching the intersphincteric plane.