Resection For Low Rectal Cancer Research Articles

Minimally invasive versus open intersphincteric resection of low rectal cancer regardless of neoadjuvant chemoradiotherapy: long-term oncologic outcomes

Intersphincteric resection (ISR) is a surgical technique intended to avoid abdominoperineal resection (APR) in patients diagnosed with low-lying rectal cancer. However, the oncologic outcomes of minimally invasive ISR are still controversial. We analyzed the long-term oncologic outcomes of open and minimally invasive ISR. A total of 313 rectal cancer patients who underwent ISR between 2000 and 2014 were analyzed, including 147 in the open surgery group and 166 in the minimally invasive surgery (MIS) group. This study also analyzed 113 patients who received neoadjuvant chemoradiotherapy (nCRT) for advanced lower rectal cancer. Propensity score matching (PSM) was used to correct for differences between the two groups. 5-year disease-free survival (DFS) rate was the primary end point. The length of hospital stay was significantly shorter in the MIS group (9.6 vs. 11.8 days, p < 0.001). Differences in overall postoperative morbidity rates between the groups were not significant; however, the rate of surgical site infection was significantly lower in the MIS group (1.2 vs. 10.9%, p < 0.001). The 5-year DFS associated with all stages combined in the matched patients were not significantly different: 75.2% in the open group vs. 64.2% in the MIS group (p = 0.214). Similar results were found in matched patients treated with nCRT, with 72.0% in the open group and 61.3% in the MIS group (p = 0.078) showing DFS. Both minimally-invasive and open ISR for rectal cancer yielded similar 5-year oncologic outcomes. MIS showed statistically significant advantages in some postoperative outcomes such as reduced surgical site infection and shorter hospital stay, and similar long-term outcomes compared with open ISR. This study also suggests that MIS after nCRT for advanced rectal cancer represents a surgical option with similar oncological results.

Sphincter-saving surgery versus abdominoperineal resection in low rectal cancer following neoadjuvant treatment with propensity score analysis.

Sphincter-saving operation is the treatment of choice in patients with lower rectal cancer, although abdominoperineal resection (APR) is necessary in some cases for adequate oncological outcomes. This study compared the oncologic outcomes of patients with low rectal cancer undergoing APR and intersphincteric resection (ISR) after neoadjuvant chemoradiotherapy (nCRT). We compared 104 patients who underwent ISR for lower rectal cancer between 2008 and 2014 with 79 patients who underwent APR during the same period. Cases in which tumors involved the levator ani muscle or the external anal sphincter, as well as those in which surgeons were unable to obtain a negative distal margin via sphincter-saving operation were excluded. Fifty-two patients who underwent ISR were matched via propensity scoring with 52 patients who underwent APR. The analyzed variables included patient and tumor characteristics and long-term outcomes before and after 1:1 propensity score matching (PSM). After matching, there were no significant differences between the two groups in clinical stage and tumor distance from anal verge. Short- and long-term outcomes were similar between the two groups. The 5-year disease-free survival rate was 76.3% in the ISR group and 57.8% in the APR group (p = 0.080). The 5-year cancer-specific survival rate was 89.5% in the ISR group and 85.4% in the APR group (p = 0.383). This reveals that ISR and APR have similar oncologic outcomes following nCRT in patients with advanced low rectal cancer adjusted for background variables.

Analysis of risk factors of anastomotic leakage after laparoscopic intersphincteric resection for low rectal cancer and construction of a nomogram prediction model

Objectives: To examine the risk factors of anastomotic leakage for low rectal cancers undergoing laparoscopic intersphincteric resection (ISR), and to construct a nomogram prediction model for it. Methods: The perioperative data of 302 low rectal cancer patients undergoing laparoscopic ISR by the same surgical team of Department of General Surgery, Peking University First Hospital between January 2012 and January 2019 were retrospectively reviewed. There were 190 males and 112 females, aging 60(14) years (range: 20 to 84 years). χ2 test, independent sample t test, U test and Logistic regression analysis were used to analyze the risk factors for anastomotic leakage. R software was used to complete the drawing of the nomogram prediction model, and the receiver operating characteristic curve was used to evaluate the predictive ability of the nomogram prediction model. Results: There were 24 patients (7.9%) had anastomotic leakage among the 302 patients enrolled, including 10 cases of grade A leakage, 9 cases of grade B leakage, and 5 cases of grade C leakage. Out of the 24 patients, 2 patients (8.3%) died, 3 patients (12.5%) received leakage-related reoperation. Median healing time of the anastomotic leakage was 74 (58) days (range: 14 to 180 days). Univariate analysis showed male gender (P=0.009), preoperative serum albumin concentration (P=0.004), neoadjuvant radiochemotherapy (P=0.017), preserving left colonic artery (P=0.002) and performing a diverting ileostomy (P=0.015) were significantly correlated with anastomotic leakage. Logistic multivariate analysis showed male gender (OR=6.052, 95%CI: 1.535 to 23.860, P=0.010), neoadjuvant radiochemotherapy (OR=4.098, 95%CI: 1.318 to 12.821, P=0.015), no preserving left colonic artery (OR=16.699, 95%CI: 3.051 to 91.406, P=0.001) and not performing a diverting ileostomy (OR=21.218, 95%CI: 4.341 to 103.710, P<0.01) were independent risk factors for anastomotic leakage. According to the results of multi-factor regression analysis, the nomogram prediction model was constructed. The area under the curve of the nomogram prediction model was 0.840 (95%CI: 0.766 to 0.914). After internal verification, the concordance index value of the model was 0.840. Conclusion: Male gender, neoadjuvant radiochemotherapy, no preserving left colonic artery and not performing a diverting ileostomy are independent risk factors for anastomotic leakage for low rectal cancers undergoing laparoscopic ISR.

Potential Benefits of Minimally Invasive Laparoscopy in Reducing Local Recurrence After Surgery for Low Rectal Cancer.

To compare the mid-term oncological results between patients with low rectal cancer who underwent minimally invasive laparoscopic surgery (MILS) and those who underwent open surgery (OS). Overall, 262 matched patients who underwent primary resection for low rectal cancer between 2000 and 2019 were divided into MILS (n=131; n=107, conventional laparoscopic surgery; n=24, robotic surgery) and OS (n=131) groups. The short- and mid-term outcomes were compared. Similar baseline characteristics were noted. The operative time was longer and blood loss was lesser in the MILS group; the conversion rate was 3.8%. The incidence of postoperative complications was similar. The 2-year cumulative incidence of local recurrence was noted to be much lower in the MILS group (1.9%) than in the OS group (8.4%). MILS had a significantly low hazard ratio (0.208, p=0.036). MILS has potential benefits in reducing local recurrence of low rectal cancer.

The transverse coloplasty pouch is technically easy and safe and improves functional outcomes after low rectal cancer resection-a single center experience with 397 patients.

Following resection for low rectal cancer, numerous patients suffer from frequent bowel movements, fecal urgency, and incontinence. Although there is good evidence that colonic J-pouch reconstruction, side-to-end anastomosis, or a transverse coloplasty pouch (TCP) improves functional outcome, many surgeons still prefer straight coloanal anastomosis because it is technically easier and lacks the risk of pouch-associated complications. The present single-center study aimed to evaluate the practicability of TCPs in routine clinical practice as well as pouch-related complications. All consecutive patients who underwent low anterior rectal resection with restoration of bowel continuity for cancer during the period September 2008 to June 2018 were included. A TCP in combination with a diverting ileostomy was defined as the hospital standard. The feasibility and safety of TCPs were assessed in a retrospective single-center study. A total of 397 patients were included in the study. A total of 328/397 patients underwent TCP construction (82.6%). Two pouch-related surgical complications occurred (0.6%); one case of pouch-related stenosis and one case of sutural insufficiency. Overall, leakage of the coloanal anastomosis was reported in 14.1% of patients with a TCP and in 18.8% of patients without a pouch (p=0.252). Diverting ileostomy was applied in 378/397 patients (95.2%). The 30-day mortality was 0.25%. The present study is by far the largest single-center experience with TCP construction for low rectal cancer resection. The study shows that a TCP is technically applicable in the vast majority of cases (82.6%). Pouch-associated surgical complications are sporadic events. In our opinion, the TCP can be considered an alternative to J-pouch construction after low anterior rectal resection.

Oncological strategy following R1 sphincter-saving resection in low rectal cancer after chemoradiotherapy

AimSphincter-saving resection (SSR) for low rectal cancer remains challenging due to the high risk of positive resection margin (R1). Long-term outcomes and the dedicated oncological strategy are not well established in this situation. The aim of this study was to define the more appropriate strategy according to the patterns of recurrence. MethodsBetween 1994 and 2014, patients treated by SSR for low rectal cancer with preoperative chemoradiotherapy were included. Three types of recurrences were defined: local (LR), distant (DR) and mixed (MR). Recurrences and survival after R0 and R1 resection were analysed by Kaplan-Meier and compared with the log-rang test. ResultsAmong 394 patients receiving SSR, 42 (10.6%) had R1 resection. Independent factors of R1 resection were EMVI (OR2.24,95%IC1.10–4.53,p = 0.025) and no tumor downstaging (OR8.41,95%IC2.50–8.32,p = 0.001). Both 5-year disease free and overall survival, and 5-year distant and local recurrence, were significantly worse after R1 resection. The overall recurrence after R1 resection was 57% (24/42), 7% had LR, 36% DR and 14% MR. Time to DR was shorter than time to LR (11.1 vs. 34.3) months. In all cases of MR, DR occurred before LR (12.1 vs. 34.3) months, meaning that after R1 resection, the first concern was DR. ConclusionR1 resection after SSR for low rectal cancer reflects a more aggressive and systemic disease. Prognosis depends on DR in about 90% of cases, suggesting that pelvic control should not be the priority in the oncological strategy after R1. Adjuvant systemic chemotherapy ought to be preferred to salvage abdominoperineal resection.

The safety of early versus late ileostomy reversal after low anterior rectal resection: a retrospective study in 47 patients

BackgroundThis study aimed to clarify the safety of early closure in diverting ileostomy with lower anterior rectal-cancer resection.MethodsWe retrospectively reviewed consecutive 47 patients who underwent diverting ileostomy with lower rectal-cancer resection between May 2009 and October 2017. The results of the stoma closure were compared between patients who underwent stoma closure within 90 days (early closure [EC] group) and those who underwent late closure (LC group; closure after 90 days). Because of the small sample size, the frequency of severe complications post closure was analyzed.ResultsAmong 47 patients, 29 were in the EC group. Postoperative complications occurred in 48.3% (14/29) and 27.8% (5/18) of patients in the EC and LC groups, respectively. This difference was due to minor complications (Clavien-Dindo Classification I/II), such as superficial incisional surgical site infections (n=5) in the EC group. The rate of severe complications (Clavien-Dindo Classification ≥ III) was similar between the groups (20.7% vs. 16.7%, p=1, Fisher’s exact test).ConclusionsNo association was observed between the time of closure and development of major complications; however, there was an increased likelihood of minor complications after EC. This study provides a basis on which future treatment guidelines for early stoma closure may be developed without affecting patient quality of life.

Laparoscopic abdominal perineal rectal resection for rectal cancer with a horseshoe kidney using preoperative 3D-CT angiography: a case report

BackgroundA horseshoe kidney is a congenital malformation involving the fusion of the bilateral kidneys and is often accompanied by anomalies of the ureteropelvic and vascular systems. When performing resection of colorectal cancer in a patient with horseshoe kidney, damage to the ureter or excessive renal arteries should be avoided. To achieve this purpose, comprehensive preoperative anatomical assessments and surgical planning are important. Here, we report a case of a laparoscopic abdominal perineal rectal resection for lower rectal cancer with a horseshoe kidney.Case presentationA 79-year-old woman presented with bloody stool and was diagnosed with advanced lower rectal cancer, immediately above the rectal dentate line, without metastasis. A preoperative computed tomography (CT) scan revealed a horseshoe kidney, while a three-dimensional CT (3D-CT) angiography revealed aberrant excess renal artery from the aorta to the renal isthmus. The left ureter ran in front of the isthmus of the horseshoe kidney and presented calculus formation. Laparoscopic abdominal perineal rectal resection was performed with D3 lymph node dissection. During the operation, we mobilized the sigmoid colon mesentery via a medial approach and preserved the left ureter, the left gonadal vessels, and the hypogastric nerve plexus in the retroperitoneum in front of the horseshoe kidney.ConclusionsWe report a rare case of rectal cancer surgery in a patient with a horseshoe kidney. We discuss the anatomical peculiarities of a horseshoe kidney, such as excess renal arteries, inferior vena cava, ureter, gonadal vessels, and nerves, that should be preserved according to the literature. We suggest that preoperative 3D-CT angiography is both useful for revealing the relationship between the vascular system and a horseshoe kidney and helpful when performing laparoscopic surgery for a left-sided colon and rectal cancer to avoid intraoperative injury.

Transanal Anastomosis Method and Prolapsing Technique in Totally Laparoscopic Low Anterior Resection for Lower Rectal Cancer

There are some reports of totally laparoscopic surgery performed by intracorporeal anastomosis without abdominal incision. However, intracorporeal anastomosis with prolapsing technique is difficult and complicated via laparoscopic surgery alone. We found it easier to achieve totally laparoscopic low anterior resection (LAR) by anastomosis anally. Our procedure was performed in 32 patients. After the prolapsed rectum with the tumor was transected, reconstruction was performed by using a double-stapling technique (DST) or a hand-sewn technique (HST). In the DST, the proximal colon was pulled outside transanally, and the anvil head was inserted into the colon and returned to the abdominal cavity. The anal-side rectum was closed using a linear stapling device, and DST was performed. The HST was modified from intersphincteric resection anastomosis. No patient experienced complications associated with this procedure. Cosmetic satisfaction was achieved. All patients obtained disease-free margins pathologically, and none experienced local recurrence. Intracorporeal anastomosis of totally laparoscopic low anterior resection is difficult via laparoscopic ports only. It can be simplified by operating with anastomosis via the anus.

Preservation of the Arterial Arc Formed by Left Colic Artery, Proximal Inferior Mesenteric Artery, and the First Branch of Sigmoid Arteries in Anus Saving Treatment of Low Rectal Cancer

Low anterior, ultralow anterior, and intersphincteric resection are conventional, elective anus-sparing techniques for low rectal cancer, and good prognosis depends on a good blood supply and tension-free anastomosis. The goal is to assess the effect of preserving the arc formed by the left colic and proximal inferior mesenteric arteries (IMAs), and first branch of the sigmoid arteries on the anastomotic blood supply, tension, and leakage rate in anus-sparing surgery for low rectal cancer. From 2011 to 2020, a patient with low rectal cancer resection was distributed into the ligation group (42 cases with inferior mesenteric artery ligation) and the preservation group (61 cases with preservation of the left colic and proximal IMAs and first branch of the sigmoid artery). We evaluated patient characteristics, operative results, morbidity, and postoperative follow-up results. There were comparable outcomes between ligation and preservation groups in relations to the number of patients in each operative procedure, duration of surgery, operative blood loss, postoperative hospital stay, and the number of patients with protective stoma (P >.05). In postoperative morbidity, there were similar outcomes between ligation and preservation groups in terms of anastomotic subclinical dehiscence, bleeding and stricture, and urinary retention (P >.05). There were significant differences in anastomotic leakage and intra-abdominal abscess (P < .05). Preservation of the arterial arc formed by left colic artery, proximal IMA, and the first branch of sigmoid arteries with apical lymph node dissection could increase anastomotic blood supply, reduce anastomotic tension, and leakage rate in anus-saving treatment of low rectal cancer.

Quality of life after sphincter preservation surgery or abdominoperineal resection for low rectal cancer (ASPIRE): A long-term prospective, multicentre, cohort study

SummaryBackgroundThe long-term effects of radical resection on quality of life may influence the treatment selection. The objective of this study was to determine whether abdominoperineal resection has a better effect on the quality of life than sphincter preservation surgery at 3 years after surgeryMethodsThis prospective, cohort study included patients who underwent radical resection for low rectal cancer. The primary outcomes were European Organisation for Research and Treatment of Cancer QLQ-C30 and CR38 quality of life scores 3 years after surgery, which were compared with linear generalised estimating equations, after adjustment for baseline values, a time effect, and an interaction effect between time and treatment. The secondary outcomes included sexual-urinary functions and oncological outcomes. The study was registered with ClinicalTrials.gov (NCT01461525).FindingsBetween December 2011 and August 2016, 342 patients were enrolled: 268 (78•4%) underwent sphincter preservation surgery and 74 (21•6%) underwent abdominoperineal resection. The global quality of life scores did not differ between sphincter preservation surgery and abdominoperineal resection groups (adjusted mean difference, 4•2 points on a 100-point scale; 95% confidence interval [CI], −1•3 to 9•7, p = 0•1316). Abdominoperineal resection was associated with a worse body image (9•8 points; 95% CI, 2•9 to 16•6, p = 0•0052), micturition symptoms (−8•0 points; 95% CI, -14•1 to −1•8, p = 0•0108), male sexual problems (−19•9 points; 95% CI, -33•1 to -6•7, p = 0•0032), less confidence in getting and maintaining an erection in males (0•5 points on a 5-point scale; 95% CI, 0•1 to 0•8, p = 0•0155), and worse urinary symptoms (−5•4 points on a 35-point scale; 95% CI, −8•0 to −2•7, p < 0•0001). The 5-year overall survival was worse with abdominoperineal resection in unadjusted (92•2% vs 80•9%; difference 11•3%, hazard ratio 2•38; 95% CI, 1•27 to 4•46, p = 0•0052), but did not differ after adjustment.InterpretationIn this long-term prospective study, abdominoperineal resection failed to meet the superiority to sphincter preservation surgery in terms of quality of life. Although the global quality of life scores did not differ between groups, this study suggests that sphincter preservation surgery can be an acceptable alternative to abdominoperineal resection for low rectal cancer, offering a better quality of life and sexual-urinary functions, with no increased oncological risk even after 3 years.FundingSeoul National University Bundang Hospital, Korea

Phẫu thuật bảo tồn hậu môn điều trị ung thư trực tràng thấp tại Bệnh Viện Ung Bướu TPHCM

Purpose: To analyse changes in performing sphincter-saving resection procedures for low rectal cancer in HCMC Oncology Hospital in the last 15 years (2004-2019). Patients and Methods: Medical records of 17 cases of low rectal carcinoma operated on from January through Juin, 2019 in Surgery Department No 2, HCMC Oncology Hospital were studied retrospectively. Data were compared to that of cases of low rectal carcinoma also operated on in HCMC Oncology Hospital from January, 2000 through December, 2004 (2004 group). Results: Compared with 2004 group, the sphincter-saving resection rate significantly increased (53% vs 4%, p&lt;0.001); although there were higher proportions of men (77% vs 36%, p=0.003) and of early stage patients (29% stage I vs 4%, p&lt;0.001). Sphincter-saving resection procedures were performed for 53% low rectal cancer patients (95% CI: 28-77%). All patients with tumors more than 3cm from the anal verge were operated on with sphincter-saving resection procedures. Conclusion: There was a significant increment of sphincter-saving resection for low rectal cancer in HCMC Oncology Hospital in the last 15 years (2004-2019). It was not different from worldwide trends.

LARS is Associated with Lower Anastomoses, but not with the Transanal Approach in Patients Undergoing Rectal Cancer Resection

BackgroundLow anterior resection syndrome (LARS) is a defecation disorder that frequently occurs after a low anterior resection (LAR) with a total mesorectal excision (TME). The transanal (ta) TME for low rectal pathologies could potentially overcome some of the difficulties encountered with the abdominal approach in a narrow pelvis. However, the impact of the transanal approach on functional outcomes remains unknown. Here, we investigated the effect of the taTME approach on functional outcomes by comparing LARS scores between the LAR and taTME approaches in patients with colorectal cancer.MethodsWe conducted a retrospective cohort study including 80 patients (n = 40 LAR-TME, n = 40 taTME) with rectal adenocarcinoma. We reviewed medical charts to obtain LARS scores 6 months after the rectal resection or a reversal of the protective ileostomy.ResultsAt the 6-month follow-up, 80% of patients exhibited LARS symptoms (44% minor LARS and 36% major LARS). LARS scores were not significantly associated with the T-stage, N-stage, or neo-adjuvant radiotherapy. The mean distance of the anastomosis from the anal verge was 4.0 ± 2.0 cm. The taTME group had significantly lower anastomoses compared with the LAR-TME group (median 4.0 cm [IQR1.8] vs. median 5.0 cm [IQR 2.0], p < 0.001). Univariable analysis revealed significantly higher LARS scores in the taTME group compared with the LAR-TME group (median LARS scores: 29 vs. 25, p = 0.040). However, multivariable regression analysis, adjusting for neo-adjuvant treatment, anastomosis distance from the anal verge, anastomotic leak rate, and body mass index, revealed no significant effect of taTME on the LARS score (adjusted regression coefficient: − 2.147, 95%CI: − 2.130 to 6.169, p = 0.359). We also found a significant correlation between LARS scores and the distance of the anastomosis from the anal verge (regression coefficient: − 1.145, 95%CI: − 2.149 to − 1.141, p = 0.026).ConclusionFifty percentage of patients in this cohort exhibited some LARS symptoms after a mid- or low-rectal cancer resection. As previously described, LARS scores were negatively correlated with the distance of the anastomosis from the anal verge. TaTME was after adjustment for the height of the anastomosis not associated with higher LARS at 6 months when compared with LAR-TME.

Arc of Riolan-Dominant Colonic Perfusion Identified by Indocyanine Green After High Ligation of Inferior Mesenteric Artery: Critical in Preventing Anastomotic Ischemia.

Arc of Riolan is a collateral mesenteric vessel observed in up to 17.8% of individuals1 bridging the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) systems perfusing the descending colon besides the marginal artery. Proximal perfusion of the anastomosis after the high division of the IMA during left-sided colorectal resections is maintained by the marginal artery, but in some, this may be absent or small-caliber at the Griffiths point.2 Identification and preservation of the arc of Riolan has been associated with a decrease in acute anastomotic ischemia events requiring resection and Hartmann's procedure, although not totally eradicated the number of anastomotic leaks requiring lesser interventions.1 This video shows the vascular supply of the left colon during a robotic ultra-low anterior resection for low rectal cancer. The arc of Riolan is identified and preserved at its usual anatomical position during the isolation and division of the inferior mesenteric vein inferior to the pancreas, lengthening the descending colon for a tension free anastomosis. The arc of Riolan is temporarily occluded with an endoscopic vascular clamp after the IMA's high division. 4mg of intravenous indocyanine green (ICG) is infused to visualize the perfusion of the descending colon for 3 minutes, which is ICG's half-life.3 The fluorescence image of the descending colon is noted to be less than expected and another 3mg of ICG is infused after unclamping the arc of Riolan, revealing a visibly higher fluorescent descending colon confirming the dominant perfusion from this vessel. ICG has clearly demonstrated the arc of Riolan's dominance in perfusing the left colon. Armed with prior knowledge, its preservation can be a critical step in preventing anastomotic ischemia after IMA's high ligation in patients with potentially weak marginal artery, whilst division of a non-dominant arc of Riolan makes splenic flexure mobilization technically less challenging. See Video Abstract at http://links.lww.com/DCR/B439.

Analysis of risk factors for anastomotic leakage after lower rectal Cancer resection, including drain type: a retrospective single-center study

BackgroundWe investigated the correlations between surgery-related factors and the incidence of anastomotic leakage after low anterior resection (LAR) for lower rectal cancer.MethodsA total of 630 patients underwent colorectal surgery between 2011 and 2014 in our department. Of these, 97 patients (15%) underwent LAR and were enrolled in this retrospective study. Temporary ileostomy was performed in each patient.ResultsAnastomotic leakage occurred in 21 patients (21.7%). Univariate analysis showed a significant association between operative duration (p = 0.005), transanal hand-sewn anastomosis (p = 0.014), and operation procedure (p = 0.019) and the occurrence of leakage. Multivariate regression reanalysis showed that underlying disease (p = 0.044), transanal hand-sewn anastomosis (p = 0.019) and drain type (p = 0.025) were significantly associated with the occurrence of leakage. The propensity-score analysis showed that closed drainage were 6.3 times more likely to have anastomotic leakage than open drainage in relation to the amount of postoperative drainage (ml), according to the inverse probability of treatment-weighted analysis.ConclusionsOur results indicate that underlying disease, transanal hand-sewn anastomosis, and closed drain may be a risk and predictive factors for anastomotic leakage after LAR for lower rectal cancer. The notable finding was that closed drainage was related to the occurrence of anastomotic leakage and closed drainage was correlated with less volume of postoperative drain discharge than open drain.

Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25-year experience from Bordeaux.

There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period. This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤6cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied. Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0cm (P<0.001) and the distal resection margin shortened from 25 to 10mm (P<0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9%vs 3.5%; P=0.741) and disease-free survival (72%vs 71%vs 75%; P=0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction. Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.

Influence of tumor location on short- and long-term outcomes after laparoscopic surgery for rectal cancer: a propensity score matched cohort study

BackgroundThis study aimed to evaluate the short- and long-term outcomes after laparoscopic resection for low rectal cancer (LRC) compared with mid/high rectal cancer (M/HRC).MethodsPatients with rectal cancer undergoing laparoscopic resection with curative intent were retrospectively reviewed between 2009 and 2015. After matched 1:1 by using propensity score analysis, perioperative and oncological outcomes were compared between LRC and M/HRC groups. Multivariate analysis was performed to identify independent factors of overall survival (OS) and disease-free survival (DFS).ResultsOf 373 patients who met the criteria for inclusion, 198 patients were matched for the analysis. Laparoscopic surgery for LRC required longer operative time (P<0.001) and more blood loss volume (P = 0.015) compared with M/HRC, and the LRC group tended to have a higher incidence of postoperative complications (16.2% vs. 8.1%, P = 0.082). There was no significant difference in local recurrence between the two groups (9.1% vs. 4.0%, P = 0.251), whereas distant metastasis was inclined to be more frequent in LRC patients compared with M/HRC (21.2% vs. 12.1%, P = 0.086). The LRC group showed significantly inferior 5-year OS (77.0% vs. 86.4%, P = 0.033) and DFS (71.2% vs. 86.2%, P = 0.017) compared with the M/HRC group. Multivariate analysis indicated that tumor location was an independent predictor of DFS (HR = 2.305, 95% CI 1.203–4.417, P = 0.012).ConclusionTumor location of the rectal cancer significantly affected the clinical and oncological outcomes after laparoscopic surgery, and it was an independent predictor of DFS.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer.

Background Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

Gender aspects of survival after abdominoperineal resection for low rectal cancer: a retrospective study.

The difference in prognosis between genders after abdominoperineal resection (APR) for low rectal cancer (LRC) is unclear. This study aimed to compare survival outcomes between genders in patients with LRC who underwent curative APR. This retrospective cohort study used a database of consecutive colorectal resections. Patients who received curative APR with LRC were grouped according to their gender. Female patients were frequency-matched 1:1 on American Joint Committee on Cancer (AJCC) stage to male patients. Overall survival (OS), disease-free survival (DFS), and their independent risk factors were examined. A total of 140 patients with APR for LRC were included after matching: 70 (50.0%) males and 70 (50.0%) females. No significant differences were found between the groups in terms of age, operation methods, AJCC stage, and adjuvant therapy (all P > 0.05). Median follow-up was 39 (range: 3-128) months. Male gender was independently associated with worse OS (adjusted hazard ratio [HR] = 2.755, 95% CI: 1.507-5.038, P = 0.001) and worse DFS (adjusted HR = 2.440, 95% CI: 1.254-4.746, P = 0.009). Subgroup analysis revealed that female patients with stage III disease had better OS (P = 0.001) and DFS (P < 0.001) than male patients. Gender affects survival after a curative APR for LRC. Compared with females, male patients with LRC after curative APR had worse prognosis, especially for stage III disease.

Intersphincteric Resection for Low Rectal Cancer: A Review of Anatomy and Surgical Techniques, Oncologic and Functional Outcomes and the Role of Robotics

Intersphincteric Resection for Low Rectal Cancer: A Review of Anatomy and Surgical Techniques, Oncologic and Functional Outcomes and the Role of Robotics