Treatment Of Ultra-low Rectal Cancer Research Articles

Evaluation of the learning curve for conformal sphincter preservation operation in the treatment of ultralow rectal cancer

BackgroundTo investigate the learning curve of conformal sphincter preservation operation (CSPO) in the treatment of ultralow rectal cancer and to further explore the influencing factors of operation time.MethodsFrom August 2011 to April 2020, 108 consecutive patients with ultralow rectal cancer underwent CSPO by the same surgeon in the Department of Colorectal Surgery of Changhai Hospital. The moving average and cumulative sum control chart (CUSUM) curve were used to analyze the learning curve. The preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data were compared before and after the completion of learning curve. The influencing factors of CSPO operation time were analyzed by univariate and multivariate analysis.ResultsAccording to the results of moving average and CUSUM method, CSPO learning curve was divided into learning period (1–45 cases) and learning completion period (46–108 cases). There was no significant difference in preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data between the two stages. Compared with the learning period, the operation time (P < 0.05), blood loss (P < 0.05), postoperative flatus and defecation time (P < 0.05), liquid diet time (P < 0.05), and postoperative hospital stay (P < 0.05) in the learning completion period were significantly reduced, and the difference was statistically significant. Univariate and multivariate analysis showed that distance of tumor from anal verge (≥ 4cm vs. < 4cm, P = 0.039) and T stage (T3 vs. T1-2, P = 0.022) was independent risk factors for prolonging the operation time of CSPO.ConclusionsFor surgeons with laparoscopic surgery experience, about 45 cases of CSPO are needed to cross the learning curve. At the initial stage of CSPO, beginners are recommended to select patients with ultralow rectal cancer whose distance of tumor from anal verge is less than 4 cm and tumor stage is less than T3 for practice, which can enable beginners to reduce the operation time, accumulate experience, build self-confidence, and shorten the learning curve on the premise of safety.

Clinical Efficacy of Intersphincteric Resection for Low Rectal Cancer Compared With Abdominoperineal Resection: A Single-Center Retrospective Study.

In recent years, intersphincteric resection (ISR) has been increasingly used to replace abdominoperineal resection (APR) in the surgical treatment of ultra-low rectal cancer. This study was to compare the clinical efficacy of ISR and APR. Between 2012 and 2018, 74 consecutive patients with ultra-low rectal cancer underwent ISR or APR in our medical center. A retrospective comparison of these 2 procedures was performed. A total of 43 patients underwent ISR and 31 underwent APR were included in the study. No significant differences were found between 2 groups in gender, age, BMI, and ASA score. Intersphincteric resection group showed shorter operative time (P = .02) and less blood loss (P = .001). Hospital stays, time to soft diet, and postoperative 30-day complications were not significantly different between the 2 groups. R0 resection achieved 100% in both the groups. As for the long-term outcomes, the survival and recurrence rate were similar between 2 groups. Moreover, the LARS and Wexner score showed that the postoperative anal function after ISR were satisfactory. This study suggested that ISR was feasible and safe for selected patients with ultra-low rectal cancer, with clinically superior outcomes in select patients (small tumors/further from the anal verge) and similar oncological outcomes to APR, and the anal functional outcomes after ISR were acceptable.

Functional outcomes with handsewn versus stapled anastomoses in the treatment of ultralow rectal cancer

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann–Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients’ expectations and promote comparable quality of life in the long-term.

Perioperative nursing of laparoscopic intersphincteric resection

Objective To explore the effective perioperative nursing method of the treatment of ultralow rectal cancer through laparoscopic intersphincteric resection (ISR).Methods Sixteen patients with ultralow rectal cancer from June 2009 to June 2011 were chosen,and all patients received the laparoscopic ISR and the perioperative nursing,and the nursing effect was observed.Results All patients could actively cooperate with the operation through perioperative nursing,and the cases of death,anastomotic leakage and postoperative bleeding were not found.All patients had the different degree of anal discomfort symptoms including the bulge,fecal urgency,anal burning,endless defecate feeling after the recovery of the anus defecation.The cases of the perianal skin eczema or ulceration were 11 cases,and the clinical features included that the stool was watery and the number of stool was frequency (3-10 times/day) ; the number of stool was gradually reduced and the time of controlling stool was gradually increased through the perioperative nursing,and most patients obtained the satisfactory bowel control 1 years after operation.The assessment of anal sphincter function one year after operation showed that the cases of A,B,C,D grade were respectively 8,4,3,1 cases,and the good rate of function in patients was 93.75％.Conclusions Perioperative nursing is very important for the laparoscopic ISR,and the attention should be paid to the perioperative nursing so as to improve the clinical efficacy. Key words: Nursing; Laparoscopy; Intersphincteric resection

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.

Intersphincteric resection for treatment of ultra-low rectal cancer

Intersphincteric resection for treatment of ultra-low rectal cancer

Long-Term Results of Intersphincteric Resection for Low Rectal Cancer

ABSTRACTBackground: The aim of this study is to investigate the long-term therapeutic outcome of intersphincteric resection (ISR) as the treatment of ultra-low rectal cancer. Methods: During January 2004 and October 2010, ISR was performed in 60 patients with ultra-low rectal cancer and their survival, local recurrence, and functional outcome were evaluated retrospectively. Results: A total of 60 patients with tumors at a median distance of 42 (range 30–50) mm from the anal verge underwent ISR. Three cases developed anastomotic leakage and two cases developed anastomotic stenosis postoperatively. After a median follow-up of 49 (range 18–90) months, local and distant recurrence occurred in six and four patients, respectively. Five-year overall and disease-free survival rates were 90.0% and 83.3%. Among them, the functional results of 53 patients suggested the mean stool frequency were 3.8 ± 1.3 (range 3–10) per 24 hr. According to Kirwan classification, good continence was shown in 73.6% of the patients. Conclusion: This preliminary study indicated that ISR might be a candidate technique in treating patients with ultra-low rectal cancer and achieved satisfactory long-term results in functional and oncologic respects.

Lymph nodes distribution and metastatic pattern of ultra-low rectal cancer after neoadjuvant therapy

To investigate the lymph nodes distribution and metastatic pattern of the ultra-low rectal cancer after neoadjuvant therapy. A total of 21 rectal cancer gross specimen after neoadjuvant therapy and 23 rectal cancer gross specimen without neoadjuvant therapy were investigated by whole mount section and tissue microarray techniques with CK20. All the patients were treated by abdominoperineal resection. There were 138 lymph nodes retrieved from the mesorectum in the neoadjuvant group including 39 metastatic lymph nodes and 12 micro-metastatic lymph nodes. Among these nodes, there were 7 rectal cancer cases with lymph nodes and 2 cases with micro-metastatic lymph nodes, and 6 cases had pathological complete remission. There were 415 lymph nodes retrieved from the mesorectum in the group without neoadjuvant therapy including 169 metastatic lymph nodes and 59 micro-metastatic lymph nodes. Among these nodes, there were 12 rectal cancer cases with lymph nodes and 4 cases with micro-metastatic lymph nodes. The proportions of metastatic lymph nodes in outer zone between the two groups were 21.5% and 29.0%, and those in pre-zone were 17.6% and 17.2% respectively. The ratio of metastatic lymph nodes in ischiorectal fossa between the two groups were 25.0% vs. 22.2% respectively. The rate of metastatic or micro-metastatic lymph nodes cases between the two groups were 4.8% vs. 13.0% respectively. The lymph nodes distribution and metastatic pattern of the ultra-low rectal cancer are affected by neoadjuvant therapy. The proportions of the anal sphincter invasion and metastatic or micro-metastatic lymph nodes in ischiorectal fossa are lower after neoadjuvant therapy. Abdominoperineal resection as the standard treatment of the ultra-low rectal cancer after neoadjuvant therapy should be re-evaluated.