Sphincter-sparing Operations Research Articles

Predictors of recurrence and long-term patient reported outcomes following surgical repair of anal fistula, a retrospective analysis

PurposeSurgery for anal fistulas can result in devastating complications, including reoperations and fecal incontinence. There is limited contemporary evidence comparing outcomes since the adoption of the ligation of intersphincteric fistula tract procedure into mainstream practice. The purpose of this study is to compare recurrence rates and long-term outcomes of anal fistula following repair.MethodsData was collected from the electronic medical records or patient reported outcomes from patients aged 18 or older with a primary or recurrent cryptoglandular anal fistula. Primary outcome was recurrence defined as the identification of at least one fistula os or a high clinical suspicion of anal fistula. Secondary outcomes included fecal incontinence and postoperative quality of life.ResultsA total of 171 patients underwent definitive surgical repairs for their anal fistula. So 66.5% had a simple fistula, and 33.5% had a complex fistula. Of the 171 patients, 12.5% had a recurrence. The recurrence rates were 5.9% for simple fistula and 25.4% for complex fistula. Predictors of recurrence included diabetes mellitus, history of anorectal abscess, complex fistula, and sphincter sparing surgery. LIFT or plug/biologic procedures were both associated with a 50% or greater recurrence rate. No significant differences were found in fecal incontinence or associated quality of life between sphincter sparing or non-sphincter sparing surgical resections.ConclusionThe study provides insights into the long-term outcomes of surgical repair for anal fistula. We demonstrate that sphincter sparing operations are associated with increased recurrence, meanwhile, non-sphincter sparing surgeries did not increase the risk of fecal incontinence or worsen quality of life.

Outcomes of the distal rectal cancer treatment depending on the type of sphincter-sparing surgery

Introduction: The increase in mid-ampullary and lower ampullary rectal cancer with disappointing treatment results requires ongoing discussion, research, and improvement of the complex treatment. Materials and methods: We analyzed the results of complex treatment in 442 patients with stages II–III mid-ampullary and lower ampullary rectal cancer that underwent three types of sphincter-sparing surgeries, including low anterior resection (LAR), intersphincteric resection (ISR), and abdomino-anal resection of the rectum (AAR) at the second stage of complex treatment. Results: There was a significant difference between groups in terms of surgery type selection based on the distance from the tumor to the dentate line. When the tumor was located at a distance of 30 mm or less from the dentate line, LAR was performed in 16.4% of cases, whereas ISR and AAR were used in 96.58 and 58.09% of cases, respectively, which is statistically significant (P<0.001). Preventive stoma was used in 78.87% of LAR, 5.9% of ISR, and 6.62% of AAR, which had a significant difference (P<0.001). In the structure of postoperative complications, a group of typical complications (ІІІ–IV) was identified for the types of operations performed. Their frequency when performing LAR was 18.2%, ISR – 7.7%, and AAR – 8.1%, which was statistically significant (P=0.003). The frequency of local recurrences, depending on the type of surgery was not statistically significant (P>0.05), but had a direct correlation with the recurrence-free survival curves. Relapse-free and overall (3 years and 5 years) survival depending on the type of sphincter-preserving surgery did not have a significant difference according to the log-rank test. Conclusion: The more types of surgical intervention surgeons have at their disposal, the more rational it is to select the one that will ensure the best treatment results.

Pelvic Recurrence After Curative Resection for Rectal Adenocarcinoma: Impact of Surgery on Survival.

Rectal cancer (RC) represents 30% of colon cancers. Despite the progress achieved in integrated chemoradiotherapy and surgical multidisciplinary treatments, the rate of local recurrence (LR) is 3.7-13%. Multivisceral resections allow many patients with pelvic recurrence to be treated in a curative manner. The purpose of this work is to assess the impact of surgery for rectal cancer patients with pelvic recurrence. In a retrospective study from 2013 to 2018, data was collected from patients who had undergone rectal resection for adenocarcinoma. We compared perioperative data, postoperative outcomes, oncological results, and survival rates. 106 rectal cancer patients (40-87 years old) requiring surgery were included. The local recurrence rate was 15% (15 patients). LR patients requiring intervention were nine (56%) who underwent sphincter sparing surgeries, and 6 (44%) who underwent surgeries with sphincter resection. There was no statistically significant difference (p=0.416) in the 5-year overall survival rate of patients without recurrence compared to those with pelvic recurrence. Curative surgery for local recurrence from rectal cancer is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.

Short-term and long-term treatment outcomes in patients with lower and middle rectal cancer with complete clinical and pathomorphological response after comprehensive treatment

Objective: to compare short-term and long-term treatment outcomes between patients with lower and middle rectal cancer with complete clinical and pathomorphological response after comprehensive treatment.Materials and methods. we performed retrospective analysis of treatment outcomes in patients with lower and middle rectal cancer. The experimental group included 27 patients with complete clinical response, whereas the control group comprised 31 patients with complete pathomorphological response (ypT0n0m0) who had undergone total mesorectal excision following neoadjuvant therapy. The main evaluated parameters included postoperative complications, proportion of R0 resections, proportion of sphincter-preserving surgeries, 2-year overall survival, and progression-free survival.Results. At a median follow-up time of 41 months (range: 25–114 months), 2 patients from the experimental group had progressive disease registered 18 and 19 months after treatment initiation; both patients underwent abdominoperineal extirpation of the rectum. The remaining 25 patients had sphincter sparing surgeries. At a median follow-up time of 48 months (range: 24–101 months), one patient was found to have liver metastasis 5 months following treatment initiation. He underwent simultaneous surgery that included low anterior resection of the rectum and liver resection and had no postoperative complications. In the group of surgical treatment, all patients underwent radical surgeries (R0), including those with permanent stoma formation (n = 11; 35.5 %) or preventive stoma formation (n = 20; 64.5 %) with subsequent bowel repair. The 2-year overall survival rate was 100 % in both groups. The 2-year progression-free survival rate was 92.6 % in the experimental group and 96.8 % in the control group (p = 0.473).Conclusion. The watch and wait strategy with active dynamic follow-up is a safe alternative to surgery in patients with complete clinical response after neoadjuvant therapy, since it ensures the results equivalent to those in patients with complete pathomorphological response.

Radiomodifiers in the combined treatment of rectal cancer patients

Objective. To evaluate the effectiveness of the combined method of treatment of patients with rectal cancer using several variants of polyradiomodification (CT+PRM). Material and methods. To increase the effectiveness of the «short» course of neoadjuvant radiation therapy (RT) 5×5 Gy until total focal dose Gy, the concept of polyradiomodification proposed by S. P. Yarmonenko (1982) was used [1]. Three radiomodifiers were used: local intracavitary microwave hyperthermia (MWH), Metronidazole (MZ) as part of a polymer composition for intrarectal administration, and the chemotherapy drug Capecitabine (Cap). Four variants of the PRM have been created, divided into two-component and three-component. Two-component variants were used when the MWH was not possible in the case of stenosis or localization of cancer in the upper ampullary rectum. Initially, Capecitabine was used at a daily dose of 1.5 g/m2 on 1–5 days in combination with a double administration of Metronidazole («Cap5+MZ») and surgery 3 weeks after RT, and later the dose of Capecitabine was increased to 2.0 g/m2 on 1–14 days («Cap14+MZ») with surgery 4–6 weeks after RT. With three-component versions of PRM, 3 additional sessions of MWH were used: «Cap5+MZ+MWH» and «Cap14+MZ+MWH». A total of 241 patients were included in the study. Results. The total toxicity in CT+PRM was 33.4%, and the overall rate of postoperative complications was 14.9%. The 5-year relapse-free survival (RFS) rate of 80.5% was achieved due to pronounced local control: cancer recurrence was detected only in 1 (0.4%) of 241 patients. This made it possible to perform sphincter-sparing operations (SSO) without compromising oncological results in 211 (86.7%) patients out of 241. The most pronounced therapeutic pathomorphosis in the tumor was achieved with «Cap14+MZ» and «Cap14+MZ+MWH»: pathomorphosis of the III degree was achieved in 9 (30.0%) of 30 patients with «Cap14+MZ», and in 13 (25.0%) of 52 patients with «Cap14+MZ+MWH», a complete pathomorphological response was detected in 7 (23.4%) of 30 patients with «Cap14+MZ», and in 9 (17.3%) of 52 patients with «Cap14+MZ+MWH». When reaching the III–IV degree of pathomorphosis, distant metastases were detected in 6.3% of patients, at the II degree and below — in 19.7% (p=0.01). Conclusion. When using CT+PRM, 5-year RFS rate was increased to 80.5%, and the frequency of SSO was increased to 86.7%, with a low level of postoperative complications (14.9%) and acceptable toxicity (33.4%).

Autologous adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistula: a prospective case-control study

BackgroundComplex cryptoglandular perianal fistula (CPAF) is a kind of anal fistula that may cause anal incontinence after surgery. Minimally invasive surgery of anal fistula is constantly emerging. Over the past 20 years, there are several sphincter-sparing surgeries, one of which is autologous adipose-derived stem cell (ADSC) transplantation. However, to date, there is no study regarding the treatment of complex CPAF with ADSC in China. This is the first study in China on the treatment of complex CPAF with ADSC to evaluate its safety and efficacy.MethodsTotally, 24 patients with complex CPAF were enrolled in this prospective case-control study from January 2018 to December 2019 in the National Colorectal Disease Center of Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine. Patients were divided into ADSC group and endorectal advancement flap (ERAF) group according to their desire. The healing of fistulas (healing of all treated fistulas at baseline, confirmed by doctor’s clinical assessment and magnetic resonance imaging or transrectal ultrasonography) was evaluated at week 12 after treatment. In addition to their safety evaluation based on adverse events monitored at each follow-up, the patients were also asked to complete some scoring scales at each follow-up including pain score with visual analog score (VAS) and anal incontinence score with Wexner score.ResultsThe closure rates within ADSC group and ERAF group at week 12 were 54.55% (6/11) and 53.85% (7/13), respectively, without significant difference between them. VAS score in ADSC group was significantly lower than that in ERAF group at the 5th day postoperatively [1(0,2) VS 2(2,4), p = 0.011], but no differences were observed at the other time. Wexner score of all patients was not increased with no significant differences between the two groups. Adverse events were observed fewer in ADSC group (27.27%) than that in ERAF group (53.85%), but there was no significant difference between them.ConclusionThis study indicated safety and efficiency of ADSC for the treatment of complex CPAF in the short term, which is not inferior to that of ERAF. ADSC may provide a promised and potential treatment for complex CPAF conforming to the future of the treatment, which is reconstruction and regeneration.Trail registrationChiCTR, ChiCTR1800014599. Registered 23 January 2018—retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=24548

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

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

Combined strategies following surgical drainage for perianal fistulizing Crohn's disease: failure rates and prognostic factors.

The medico-surgical strategy for the treatment of perianal fistulizing Crohn's disease (CD) following surgical drainage remains challenging and debated. Our aims were to describe the failure rate of therapeutic interventions after drainage of the fistula tract and determine the factors associated with failure to optimize medico-surgical strategies. All consecutive patients with perianal fistulizing CD who underwent surgical drainage with at least a 12-week follow-up were included. Failure was defined as the occurrence of at least one of the following items: abscess recurrence, purulent discharge from the tract, visible external opening and further drainage procedure(s). One hundred and sixty-nine patients were included. The median follow-up was 4.0years. The cumulative failure rates were 20%, 30% and 36% at 1, 3 and 5years, respectively. The cumulative failure rates in patients who had sphincter-sparing surgeries or seton removal were significantly higher than in those who had a fistulotomy. Anterior fistula [hazard ratio (HR)=2.52 (1.13-5.61), P=0.024], supralevator extension [HR=20.78 (3.38-127.80), P=0.001] and the absence or discontinuation of immunosuppressants after anal drainage [HR=3.74 (1.11-12.5), P=0.032] were significantly associated with failure in the multivariate analysis model. Combined strategies for perianal fistulizing CD lead to a failure rate of 36% at 5years. Where advisable, fistulotomy may be preferred because it has a lower rate of recurrence. The benefits of immunosuppressants require a dedicated prospective randomized trial.

Outcomes of sphincter-sparing surgeries in patients with rectal cancer: long-term experience of a specialized clinic

Background. In this article, we analyze a 30-year experience of treating patients with rectal cancer and outcomes of sphincter-sparing surgeries (SSS) with manual coloanal anastomosis or mechanical colorectal anastomosis combined with various therapies. Objective: to optimize the indications for SSS considering tumor stage, treatment strategy, and overall performance status of a patient. Materials and methods . We analyzed short-term and long-term treatment outcomes of 1,440 patients with stage T2—3N0—2M0 rectal adenocarcinoma who underwent both surgery and various neoadjuvant therapies. A total of1,038 SSS were included into the final analysis. Four hundred and eighty-one patients underwent anterior rerections (AR) with mechanical anastomosis; 557patients underwent abdominoanal resections (AAR) with manual coloanal anastomosis; of them, 289 individuals had modified abdominoanal resection. Results. The overall frequency of postoperative complications after SSS was 24.3 %. The frequency of anastomosis leakage after AAR and AR was 9.5 % and 15 % respectively. Among patients with middle rectal cancer, there was no association between the type of surgery (AR or AAR) and the probability of relapse (p = 0.1823). In the subgroup with lower rectal cancer, patients that underwent abdominoperineal resection were more likely to have a relapse than those who underwent AAR (p = 0.042). The five-year overall survival rate reached 80 % in the group of SSS and 71 % in the group of abdominoperineal resection (p = 0.013). Year-on-year analysis of relapse-free survival after SSS demonstrated that it had significantly increased (from 63.5 % to 72.5%; p = 0.00077). The complex of rehabilitation measures in the early postoperative period after SSS ensures good functional effect in 51.5 % of cases. Conclusions. SSS planning should be considered from the standpoint of clinical experience as well as multivariate analysis of short-term and long-term treatment outcomes. Successful outcomes can be achieved by a combination of adequate surgical techniques and conservative rehabilitation even in patients with very low rectal cancer. Such combination ensures not only good cancer outcome, but also satisfactory functional results.

Low anterior resection syndrome: a survey of the members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP).

Low anterior resection syndrome (LARS) is frequent following sphincter-sparing procedures for rectal cancer. This study aims to assess surgeons' awareness of LARS. This was a survey study. Members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP). Three hundred thirty-four surgeons from the ASCRS and 150 from the Spanish Societies completed a 23-item electronic questionnaire. Surgeons' opinions regarding different aspects of LARS. The proportion of rectal cancer patients undergoing sphincter-sparing operations ranged between 71 and 90 %. Low anterior resection with end-to-end anastomosis was the most frequently cited procedure after mesorectal excision. More than 80 % of participants were recognized to be moderately or extremely aware of the condition, but regarding the method used to assess LARS, the majority relied on clinical manifestations. Around 35 % of surgeons considered that severe LARS developed in less than 40 % of patients. The most important factor related to defecatory function impairment in the surgeons' opinion was the distance from the anal margin to anastomosis. Other factors thought to be involved were anastomotic leakage, preoperative radiation therapy, age, and postoperative radiotherapy, with similar percentages in the two groups of surgeons. Lifestyle changes and dietary measures associated with or without drug treatment was the modality of choice. The experience with transanal irrigation or sacral nerve stimulation was limited. It was considered that <30 % of patients chronically suffer from severe LARS with significant quality of life impairment. The limitations of this study are the international mix and expert status of the specialists. The probability of patients suffering from LARS was underestimated despite reporting good knowledge of the syndrome. Validated methods for the assessment of LARS were rarely used. Deficient awareness regarding risk factors for LARS was documented. Knowledge of therapeutic options was also limited.

P-336 Effect of radiotherapy on sphincter-sparing operations rate in rectal cancer patients

Introduction: Neoadjuvant radiotherapy (RT) is widely used as a standard treatment option for distal rectal cancer (T3-T4N + /-). Using RT leads to a decrease of tumor size (downsizing) and reduction of disease stage (downstaging), which increases the number of sphincter-sparing operations (SSO) in patients who were previously candidates for abdomino-perineal excision.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution

BackgroundMultivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. MethodsA retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. ResultsSixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. ConclusionsMultivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.

Treatment of Refractory Perianal Fistulas with Ligation of the Intersphincteric Fistula Tract: Preliminary Results

Several surgical options exist for management of fistula in ano. The goal of treatment is to achieve closure of the fistula while maintaining continence. Sphincter-sparing operations to close perianal fistulas include advancement flap, anal fistula plug, fibrin glue, and fistulectomy. Variable success rates from 30 to 80 per cent have been reported. Ligation of intersphincteric fistula tract (LIFT), first described in 2007, has a reported success rate from 40 to 94 per cent. The objective of this study was to study our results of the LIFT procedure for refractory perianal fistulas. We conducted a retrospective 18-month review of consecutive patients with refractory perianal disease treated with the LIFT procedure at an academic, tertiary, colorectal practice. All patients undergoing a LIFT procedure for anal fistula from August 2010 to August 2012 were included in the study. The primary end points were success rates at 1 month and 3 months. Secondary end points were postoperative complications and maintenance of continence. Twenty patients underwent LIFT procedures of whom nine had previously failed treatments. Mean age was 45 years and included 12 male and eight female patients. Success rate at 1 month was 70 per cent (14 patients) and at 3 months was 80 per cent (16 patients). Success rates for patients with previously failed attempts were 67 per cent at 1 month and 89 per cent at 3 months. Continence was maintained in 100 per cent of patients. Our data support the use of the LIFT procedure for refractory perirectal fistulas.

Sovremennye printsipy lecheniya raka pryamoy kishki

The present overview is dedicated to the current principles of surgical and combination treatment for rectal cancer. Basic approaches to choosing a treatment method and policy for early (T1-2N0) and locally advanced (T3-4 and/ or N1) rectal cancer are described. The role of the current chemoradiotherapy as a factor that reduces the frequency of local recurrences and increases the number of sphincter-sparing operations is considered. Great emphasis is laid on the role of a pathomorphologist in the assessing the quality of surgical intervention on the basis of macroscopic and microscopic studies. An integrated assessment of the factors that influence prognosis and quality of life in patients with rectal cancer is given; these include total mesorectumectomy, nerve-sparing surgery, circular resection edge, and extended lateral lymphadenectomy.

Sovremennye printsipy lecheniya raka pryamoy kishki

The present overview is dedicated to the current principles of surgical and combination treatment for rectal cancer. Basic approaches to choosing a treatment method and policy for early (T1-2N0) and locally advanced (T3-4 and/ or N1) rectal cancer are described. The role of the current chemoradiotherapy as a factor that reduces the frequency of local recurrences and increases the number of sphincter-sparing operations is considered. Great emphasis is laid on the role of a pathomorphologist in the assessing the quality of surgical intervention on the basis of macroscopic and microscopic studies. An integrated assessment of the factors that influence prognosis and quality of life in patients with rectal cancer is given; these include total mesorectumectomy, nerve-sparing surgery, circular resection edge, and extended lateral lymphadenectomy.

Early Results of a Pilot Study of Intra-tumoral Injection of TNFerade TM Biologic Concurrent With Neoadjuvant Chemoradiation Therapy for the Treatment of Primary and Recurrent Rectal Cancer

Purpose/Objective(s): Neoadjuvant chemoradiation has evolved as the standard of care for locally advanced rectal cancer. With current treatment approaches less than one quarter of patients achieve a complete pathologic response. Local delivery of TNFerade biologic TM, a second generation replication deficient adenoviral vector expressing human TNF alpha regulated by the radiation inducible promoter Egr1, has shown potential for improving pathologic response rates in several solid tumors when delivered with radiotherapy. This pilot study assesses the feasibility of incorporating weekly intratumoral injections of TNFerade with standard neoadjuvant chemoradiation for locally advanced rectal cancer. Materials/Methods: Our ongoing feasibility study has enrolled 7 patients with locally advanced or recurrent rectal cancer who have not received prior radiation therapy. Weekly endoscopic or CT-guided intratumoral injections of TNFerade were given at a dose of 4.0 x 10^10 PU during the first five weeks of radiotherapy. Pelvic radiation using three or four fields was delivered at 1.8Gy per fraction, five days a week to a total of 45Gy followed by a boost of 5.4-9Gy to the gross tumor volume with margin. All patients received oral capecitabine at a dose of 937.5mg/m2 BID on weekdays. Resection was completed 69 weeks following induction therapy. Results: Currently, six patients have completed treatment with no toxicity attributable to TNFerade injections. The average time from TNFerade injection to the next radiation treatment was 3.7 hours. Five patients had T3 disease, one had T4 disease and two were node positive. Four patients were deemed to require APR prior to therapy, however all six patients who have undergone surgical resection have successfully undergone sphincter sparing surgeries. Four patients achieved a complete pathologic response defined as less than 10% viable tumor. Toxicity was scored according to RTOG guidelines. A single patient experienced capecitabine related on treatment grade 3 hematologic toxicity and did not complete the final week of capecitabine. This patient also experienced acute grade 4 ileitis in the radiation field and underwent ileal resection at the time of LAR. Otherwise, gastrointestinal toxicities secondary to radiation were mild. There was one grade 1 late vaginal stenosis attributed to radiation treated with occasional dilation and hormone cream. No long-term grade 3-4 toxicities have been observed. One patient developed metastatic pulmonary disease but is now clinically free of disease following wedge resection. Conclusions: These initial data indicate the addition of TNFerade TM biologic to standard neoadjuvant chemoradiation may provide excellent rates of both pathologic complete responses and sphincter sparing procedures. Weekly endoscopic or CT-guided intratumoral injections are both feasible and well tolerated. If this preliminary data is representative of the complete trial results, comparison of this regimen to standard therapy in a prospective randomized trial is warranted.

Abdominoperineal Resection: How Is It Done and What Are the Results?

Abdominoperineal resection (APR) for many years was the treatment of choice for most patients with rectal cancer. Recent advances in surgical technique and other treatment modalities have led to a marked increase in the rate of sphincter-sparing operations, with a concomitant decrease in APR. However, it is still necessary in selected patients, especially those with very distal tumors or poor sphincter function. This review will cover the history of APR, current operative strategy and complications, oncologic and quality of life results, as well as potential future advances.

Treatment Disparities in Hispanic Rectal Cancer Patients: A SEER Database Study

Although Hispanics demonstrate a low overall incidence of rectal cancer, mortality rates have not decreased relative to non-Hispanic whites. To determine if this was in part due to racial disparities in care, we compared rates of neoadjuvant therapy and sphincter-preserving surgery between Hispanics and non-Hispanic whites diagnosed with rectal cancer using the Surveillance, Epidemiology, and End Results (SEER) database. The study population was comprised of 2,573 Hispanics (55.4% male) and 28,395 non-Hispanic whites (56.6% male). Rates of neoadjuvant radiation were 13.5 per cent for Hispanics compared with 10.4 per cent for non-Hispanic whites (P < 0.001). In a Cox proportional hazards model adjusting for nodal status, tumor size, and T stage, non-Hispanic whites were significantly less likely to have received neoadjuvant therapy (hazard ratio, 0.72; P < 0.001; 95% confidence interval 0.63-0.83). Rates of sphincter preservation were 67 per cent for Hispanics and 70 per cent for non-Hispanic whites (P = 0.003). Non-Hispanic whites were significantly more likely to have received a sphincter-preserving operation than Hispanics (hazard ratio, 1.076; P = 0.019; 95% confidence interval 1.02-1.27). We conclude that Hispanics are significantly more likely to receive neoadjuvant therapy but are less likely to receive sphincter-sparing operations for rectal cancer compared with non-Hispanic whites. Further studies are required to assess the impact of these treatment disparities on patient outcome.

Gastrointestinal stromal tumors of the anorectum — A special entity: GISTs of the anorectum

ObjectiveUntil recently gastrointestinal stromal tumor (GIST) has been separated from other mesenchymal neoplasms and categorized as a special entity. Morphology of tumor cells and immunohistochemical findings with CD117 are crucial in the pathological diagnosis of GISTs. Newly developed drug imatinib mesylate (formerly called STI571) has been proved effective for GISTs. The distinction of GISTs and other mesenchymal tumors has great clinical significance, especially for lesions located in the anorectum.MethodsThe authors searched the database of Peking University, School of Oncology for patients with anorectal neoplasms treated from January 1995 to June 2002. Information of 12 patients with anorectal mesenchymal tumors was collected. The patients were reevaluated and discussed according to current criteria of GISTs with clinical data and immunohistochemical findings.ResultsSix patients (including 3 males) were finally diagnosed as anorectal GISTs. The median age of those patients was 59.5 years (27∼69). The symptoms were not specific. Three cases with original diagnosis of leiomyoma or leiomyosarcoma were actually GISTs. A total of six anorectal GISTs was found comprising about 1.06% of patients with anorectal neoplasmas in the same period. Besides CD117, CD34 and vimentin were also expressed in majority of these patients. Five of the six patients underwent surgical resection one of which received neoadjuvant chemotherapy before resection.ConclusionAnorectal GISTs should be considered as a special entity using current diagnostic criteria. Surgical resection remains the primary therapeutic strategy. Neoadjuvant imatinib mesylate may be helpful in sphincter-sparing operations and improvement of the quality of life for these patients.

Impact of hospital procedure volume on surgical operation and long-term outcomes in high-risk curatively resected rectal cancer: findings from the Intergroup 0114 Study.

Prior studies have demonstrated superior outcomes after a curative surgical resection of rectal cancer at hospitals where the volume of such surgeries is high. However, because these studies often lack detailed information on tumor and treatment characteristics as well as cancer recurrence, the true nature of this relation remains uncertain. We studied a nested cohort of 1,330 patients with stage II and stage III rectal cancer participating in a multicenter, adjuvant chemoradiotherapy trial. We analyzed differences in rates of sphincter-preserving operations, overall survival, and cancer recurrence by hospital surgical volume. We observed a significant difference in the rates of abdominoperineal resections across tertiles of hospital procedure volume (46.3% for patients resected at low-volume, 41.3% at medium-volume, and 31.8% at high-volume hospitals; P <.0001), even after adjustment for tumor distance from the anal verge. However, this higher rate of sphincter-sparing operations at high-volume centers was not accompanied by any increase in recurrence rates. Hospital surgical volume did not predict overall, disease-free, recurrence-free, or local recurrence-free survival. However, among patients who did not complete the planned adjuvant chemoradiotherapy (270 patients), those who underwent surgery at low-volume hospitals had a significant increase in cancer recurrence (adjusted hazard ratio, 1.94; 95% CI, 1.01 to 3.72; P =.04 for the trend) and a nonsignificant trend toward increased overall mortality (P =.08) and local recurrence (P =.10). In contrast, no significant volume-outcome relation was noted among patients who did complete postoperative therapy. Using prospectively recorded data, we found that hospital surgical volume had no significant effect on rectal cancer recurrence or survival when patients completed standard adjuvant therapy. Sphincter-preserving surgery was more commonly performed at high-volume centers.