Sphincter-saving Resection For Rectal Cancer Research Articles

Long-term functional and oncological results after sphincter-saving resection for rectal cancer - Cohort study

PurposeThe treatment of rectal cancer could be complex and the long term complications have the potential to greatly impact the quality of life. The aim of this study was to evaluate the long term functional and oncological results after sphincter-saving resection for rectal cancer. MethodsBetween January 2005 and December 2013, a total of 187 rectal resections with total mesorectal excision (TME) for cancer were performed. The data of 72 (38.5%) patients were available for analysis. Long-term follow-up was used to analyze the oncologic and functional results. Standardized questionnaires were used to determine fecal incontinence and urinary function. Relevant clinical variables were evaluated using univariate and multivariate analyses. ResultsThe overall survival rate was 71% and the distribution of the International Union against Cancer (UICC) stages was 48.6% stage 1, 18% stage 2, and 33.3% stage 3. In univariate analysis, neoadjuvant radiotherapy (P < 0.01), rectal pouch (P < 0.01) and hand-sewn anastomosis (P = 0.02) was found to adversely affect fecal continence. On multivariate analysis fecal incontinence was significantly correlated with neoadjuvant radiochemotherapy (P < 0.05) and low rectal resection (P < 0.01). Urinary function was not statistically significant affected by preoperative treatment (P = 0.48) or surgical procedure (P = 0.45). ConclusionTumor location, surgical technique and neoadjuvant treatment had an impact on long term oncologic and functional results after sphincter-saving resection for rectal cancer. Urinary dysfunction occurs less frequently than anal disorders. These results highlight the importance of functional evaluation before and after rectal cancer resection in daily clinical practice and the necessity to tailor treatment to each patient.

Defining the distal margin of rectal cancer for surgical planning

Accurate measurement of the distal rectal tumor margin is essential in selecting the appropriate surgical procedure. However, there is no standard measurement method. The National Cancer Institute consensus group recommends use of the anal verge (AV) as a landmark, and the European Society of Gastrointestinal and Abdominal Radiology recommends use of the anorectal ring (ARR). In addition, whether measurements should be made on double contrast barium enema (BE) radiographs or magnetic resonance (MR) images remains controversial. We measured the distal tumor margin on both BE and MR images obtained preoperatively from 52 patients who underwent sphincter-saving resection for rectal cancer. The distances from the distal end of the tumor to the AV and the ARR were measured on both types of images, and the variability was investigated by Bland-Altman analysis. The mean distance from the tumor to the AV was 8.9 cm on the BE radiographs and 7.7 cm on the MR images (P=0.013). The mean distances to the ARR were 6.8 and 5.6 cm, respectively (P=0.070). Significant proportional bias was shown as the measured distances increased, the difference between the BE- and magnetic resonance imaging (MRI)-based measurements increased. Use of one or the other landmark did not affect selection of the appropriate surgical procedure. We conclude that an approximate 1-cm underestimation should be taken into account when MRI-based measurement of the distal rectal tumor margin is used to choose between sphincter-saving resection and abdominoperineal resection.

Oncologic outcomes in rectal cancer patients with a ≤1-cm distal resection margin.

Recently, common application of sphincter-saving resection in rectal cancer has led to acceptance of a 1-cm distal resection margin (DRM). The aim of this study was to evaluate oncologic outcomes of a DRM ≤1cm in sphincter-saving resection for rectal cancer. The outcomes of a DRM ≤0.5cm was also evaluated. We reviewed prospectively collected data from 415 patients who underwent sphincter-saving resection for mid and low rectal cancer between September 2006 and December 2012 at Korea University Anam Hospital. Patients were divided into two groups according to DRM measured in a formalin fixed specimen: ≤1cm (n=132) and >1cm (n=283). The DRM ≤1cm group was divided into two subgroups: ≤0.5cm (n=45) and >0.5, ≤1cm (n=87). Median follow-up periods were 47.2months. The 5-year local recurrence rate was 8.8% in the DRM ≤1cm group and 8.5% in the DRM >1cm group (p=0.630). The 5-year disease-free survival rate was 75.1 and 76.3% (p=0.895), and the 5-year overall survival rate was 82.6 and 85.9% (p=0.401), respectively. In subanalysis of the DRM ≤1cm group, there was also no significant difference in the local recurrence and survival. There was no significant difference in local recurrence and survival based on DRM length. We found that DRM length less than 1cm was not a prognostic factor for local recurrence or survival.

Surgery for rectal cancer after high-dose radiotherapy for prostate cancer: is sphincter preservation relevant?

The feasibility and outcome of sphincter-saving resection for rectal cancer were assessed in patients previously treated by high-dose radiotherapy for prostate cancer. Between 2000 and 2012, 1066 patients underwent rectal excision for rectal cancer. Of these, 236 were treated by conventional radiotherapy (45 Gy) and sphincter-saving resection (Group A) and 12 were treated by external-beam radiotherapy (EBRT) for prostate cancer (70 Gy) and sphincter-saving resection (Group B) of whom five had a metachronous and seven a synchronous cancer. The end-points were surgical morbidity, pelvic sepsis, reoperation and definitive stoma. Tumour characteristics were similar in both groups. Surgical morbidity (67% vs 25%, P = 0.004), anastomotic leakage (50% vs 10%, P = 0.001, and reoperation (50% vs 17%, P = 0.011) were significantly higher in Group B. Multivariate analyses showed that EBRT for prostate cancer was the only independent factor for anastomotic leakage (OR = 5.12; 95% CI 1.45-18.08; P = 0.011) and definitive stoma (OR = 10.56; 95% CI 3.02-39.92; P < 0.001). High-dose radiotherapy for prostate cancer increases morbidity from rectal surgery and the risk of a permanent stoma. This suggests that a delayed coloanal anastomosis or a Hartmann procedure should be proposed as an alternative to low anterior resection in this population.

Characteristics and Risk Factors Associated with Permanent Stomas After Sphincter‐Saving Resection for Rectal Cancer

The aim of the present study was to identify the risk factors and patient characteristics associated with permanent stomas after sphincter-saving resection for rectal cancer. Between 2000 and 2007, 2,362 patients underwent sphincter-saving surgery [low anterior resection or ultra-low anterior resection (uLAR)] for rectal cancer. These patients were divided into two groups: 71 patients with permanent stomas and 2,291 patients without permanent stomas after rectal cancer surgery. Of the 71 permanent stomas (3 % of the patients), 34 (48 %) were ileostomies, 11 (15 %) were loop colostomies, 10 (14 %) were treated by Hartmann's operation, and 16 (23 %) were treated by abdominoperineal resection. Diverting stomas were created in 364 patients; 3 % (n = 11) of them could not be reversed due to anastomosis-related complications. Permanent stomas were constructed at a median of 20 months after sphincter-saving surgery for rectal cancer. The main causes of permanent stomas were local recurrence (n = 27), anastomotic leakage (n = 12), fistula (n = 9), and anastomosis site stricture (n = 7). The main causes of early permanent stomas (<1 year) were anastomosis-related complications, whereas for late permanent stomas (≥1 year), the main cause was local cancer recurrence. The independent risk factors for permanent stomas were local recurrence, postoperative pelvic sepsis, male gender of the patient, the uLAR operation type, and perioperative radiation therapy. In a high-volume surgical center, sphincter-saving surgery for rectal cancer is associated with a low incidence of permanent stoma.

Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer

Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR. Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n = 27), asymptomatic 7% (n = 14)]. Possible risk factors for DS after AL were analysed. Management of AL consisted in no treatment (n = 14), medical treatment (n = 6), local drainage (n = 10) and abdominal reoperation (n = 11). After a median follow-up of 38 months, the overall rate of DS was 3% (n = 6): 0% for asymptomatic vs 22% after symptomatic AL (P = 0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P = 0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score > 2 and abdominal reoperation for AL. The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed.

Abdominoanterior sagittal approach for sphincter-saving low anterior resection for carcinoma of the rectum in females: a modified anatomical approach

Safe access to the lower rectum is of the utmost importance when performing sphincter-saving resection for rectal cancer. We describe an abdominoanterior sagittal approach for low anterior resection in females. The abdominal part of the procedure is similar to conventional low anterior resection. The perineal part includes making an anterior sagittal incision from the posterior fourchette to the anterior edge of the anus. The use of a muscle stimulator allows identification of the external sphincters. The rectum and both puborectal slings are identified. Lower margin division and completion of total mesorectal excision is done from below, under vision. The specimen is delivered and mobilized colon is brought down, a hand-sewn end-to-end colorectal anastomosis is formed, and a diverting colostomy is fashioned. Seven patients underwent low anterior resection via the abdominoanterior sagittal approach. Two patients (29%) developed anastomotic stricture, one in association with a rectovaginal fistula and still had a defunctioning stoma, while the other responded to dilatation. The six patients who underwent stoma closure achieved continence to solid stools with a mean Kelly score of 5. The abdominoanterior sagittal approach for low anterior resection is an alternative option for sphincter-saving resection in female patients as it defines the sphincteric anatomy, and minimizes the risk of sphincter injury.

Is a Short Distal Resection Margin of Less than One Centimeter in a Sphincter-saving Resection for Rectal Cancer Oncologically Safe?

Purpose: Sphincter preservation is one of the main goals in the treatment of rectal cancer. The aim of this study was to evaluate the oncologic safety of a sphincter-saving resection with a distal resection margin of less than 1 cm. Methods: Two hundred forty-eight patients who underwent a sphincter-saving resection between June 1989 and December 2002 and who had a confirmed distal resection margin of less than 1 cm on pathologic examination were included. All patients were evaluated for local and systemic recurrences. Results: The median follow-up period was 45 (6∼144) months. The mean length of distal resection margin was 0.79±0.26 cm. Lower rectalcancer was most common (56.5%). Forty patients (16.1%) experienced recurrence. The local recurrence rate was 3.6%, systemic recurrence rate was 11.7%, and the combined local and systemic recurrence rate was 0.4%. In systemic recurrence, the liver was the most common site, followed by the lung. Among stage II & III groups, patients who underwent adjuvant chemoradiotherapy experienced significantly lower local recurrence compared to patients in the chemotherapy- only or the no-adjuvant group (2.6%, 12.9%, 8.7%, P=0.05). The length of distal resection margin, the total mesorectal excision, the location of tumor, sex, histology, and stage were not associated with local recurrence. Conclusions: A distal resection margin of less than 1 cm in a sphincter-saving resection showed acceptableoncologic outcomes. Adjuvant chemoradiotherapy were beneficial to reduce local recurrence in the stage II and the stage III groups.

Long-term functional results after sphincter-saving resection for rectal cancer

A number of patients suffer from gastrointestinal side effects following sphincter-saving resection of the rectum. The aim of this study was to assess frequency and risk factors of long-term gastrointestinal side effects after sphincter-saving resection for rectal cancer. Between 1980 and 1997, among 209 patients treated for rectal cancer by rectal resection and sphincter conservation, 145 who were alive without recurrence or colostomy, responded to a questionnaire. There were 85 males and 60 females with a mean age of 64 Years; the follow-up was 5.4 Years. The functional result was considered good if the number of stools per 24h was three or less with normal continence and poor if the number of stools was four or more or if fecal incontinence was present. Influence of age, gender, anastomotic height, type of sutured colon, colonic pouch, defunctioning stoma, leakage, stenosis, radiotherapy, history of irritable bowel syndrome and follow-up were analyzed. The mean anastomotic height was 5 cm from the anal margin. Functional results were good in 56% of patients and poor in 44%. Univariate analysis showed three variables to be significantly associated with the functional results: anastomotic height (P=0.001), radiotherapy (P=0.03) and follow-up > 24 Months (P=0.009). Multivariate analysis showed that only anastomotic height independently influenced functional results. They were good in 76%, 53% and 35% of patients for anastomoses located above 6 cm, between 6 and 3 cm, and below 3 cm from the anal margin, respectively. After sphincter-saving resection for rectal cancer, about half of patients have poor long-term functional results, the latter being related only to the anastomotic height. This suggests the need to preserve a small part of the rectum when oncologically feasible.

Risk factors for anastomotic leakage after resection of rectal cancer.

The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage, which is associated with a 6-22 per cent mortality rate. The aim of this retrospective study was to evaluate the risk factors for clinical anastomotic leakage after anterior resection for cancer of the rectum. From 1980 to 1995, 272 consecutive anterior resections for rectal cancer were performed by the same surgical team; 131 anastomoses were situated 5 cm or less from the anal verge. The associations between clinical anastomotic leakage and 19 patient-, tumour-, surgical-, and treatment-related variables were studied by univariate and multivariate analysis. The rate of clinical anastomotic leakage was 12 per cent (32 of 272). Multivariate analysis of the overall population showed that only male sex and level of anastomosis were independent factors for development of anastomotic leakage. The risk of leakage was 6.5 times higher for anastomoses situated less than 5 cm from the anal verge than for those situated above 5 cm; it was 2.7 times higher for men than for women. In a second analysis of low anastomoses (5 cm or less from the anal verge; n = 131), obesity was statistically associated with leakage. A protective stoma is suitable after sphincter-saving resection for rectal cancer for anastomoses situated at or less than 5 cm from the anal verge, particularly for men and obese patients.

Anastomotic recurrence after sphincter-saving resection for rectal cancer. Length of distal clearance of the bowel.

A retrospective study of anastomotic recurrence after sphincter-saving resection for rectal cancer is presented. During the 21 years from 1962 to 1982, 273 patients with rectal cancer underwent sphincter-saving resection and 30 (11 percent) of them had anastomotic recurrences. Computer analysis of 69 variables was undertaken to identify factors contributing to the anastomotic recurrence, with special reference to the length of distal clearance of the bowel. There was no significant correlation between the incidence of recurrence and the length of distal clearance of the bowel, if the latter was over 2 cm. There appears to be justification for carrying out a curative sphincter-saving operation for cases in which more than a 2-cm distal margin can be afforded. However, for cancers of the infiltrating type, annular growths, invasion to adjacent organs or mucinous features, a more extensive distal clearance of the bowel is necessary, and the Miles operation should be performed.