Upper Rectal Cancer Research Articles

Short- And medium-term outcomes of reduced-port laparoscopic surgery in elderly patients with upper rectal cancer: A retrospective cohort study.

ABSTRACTBackgroundTo investigate the short‐ and medium‐term outcomes of using a reduced‐port laparoscopic surgery (RPLS), compared to multi‐port laparoscopic surgery (MPLS), for the treatment of upper rectal cancer (URC) among elderly patients.MethodsWe conducted a retrospective analysis of the clinical and follow‐up data of 181 elderly patients with URC, who underwent radical laparoscopic surgery at our hospital, between January 2015 and January 2019. Among these 181 cases, 62 underwent RPLS and 119 MPLS.ResultsCompared to MPLS, RPLS decreased the length of surgical incision, lower pain on postoperative days 1 and 2, decreased the time to first flatus after surgery, as well as the time to mobilization after surgery. There was no difference between the short‐term outcomes between the two laparoscopic approaches, and no difference in the 3‐year disease‐free and overall survival rate.ConclusionCompared to MPLS, RPLS provides several advantages for the treatment of URC among elderly individuals, including a shorter length of surgical incision, reduced postoperative pain, shorter time to first flatus after surgery, earlier mobilization, and better cosmetic outcomes. These advantages are achieved with no difference in the length of surgery, nor in the 3‐year disease‐free and overall survival rate, compared to MPLS.

Laparoscopic Partial Resection of the Urinary Bladder for Colorectal Cancers With Suspected Urinary Bladder Invasion

Introduction Although partial cystectomy has been performed by laparoscopy in patients with benign disease, there have only been a few reports regarding the laparoscopic partial resection of urinary bladder–adherent colorectal cancer. This study was conducted to evaluate the short-term surgical outcomes of laparoscopic partial resection of urinary bladder–adherent colorectal cancer. Case presentation Between April 2014 and February 2017, 6 patients with colorectal cancers that were adherent to the urinary bladder underwent laparoscopic colorectal cancer resection combined with partial cystectomy. Their surgical outcomes were reviewed retrospectively. The primary colorectal cancer was located in the sigmoid colon in 5 patients and the upper rectum in 1 patient. None of the patients required conversion to open surgery. The median duration of surgery was 411 minutes, and the median amount of intraoperative blood loss was 284 mL. In the patients with sigmoid colon cancer, the bladder was primarily closed under direct visualization via the small lower abdominal incision used to remove the tumor. In the patient with upper rectal cancer, the bladder was primarily closed laparoscopically. None of the patients demonstrated urinary leakage on retrograde cystography or anastomotic leakage, and there were no cases of perioperative mortality or morbidity. None of the patients developed recurrence of cancer at the median follow-up of 21 months. Conclusion Laparoscopic partial resection of urinary bladder–adherent colorectal cancer produces good short-term outcomes without increasing morbidity. Performing bladder closure under direct visualization via a small lower abdominal incision might be useful in selected patients.

Neoadjuvant Treatment in Upper Rectal Cancer Does Not Improve Oncologic Outcomes But Increases Postoperative Morbidity.

Neoadjuvant chemoradiation/radiation therapy in locally advanced (LA) upper rectal adenocarcinoma management remains unclear. The aim of this study was to compare outcomes between neoadjuvant chemoradiation therapy (CRT) and upfront surgery (US). A total of 127 patients were retrospectively included from 5 centers (79 treated with US and 48 with CRT). CRT and US groups were compared in terms of postoperative complications and long-term oncological and functional results. Total mesorectal excision (TME) was more frequent in CRT (58% vs. 20% in US, p<0.001). CRT was associated with more overall and severe postoperative complications (60% vs. 30%, p<0.001 and 17% vs. 1%, p=0.002, respectively), and was the only risk factor [OR=18.8 (2.2-160.2), p=0.007]. Five-year overall survival and 5-year recurrence-free survival were similar between CRT and US (96% vs. 91% p=0.256 and 85.4% vs. 85%, p=0.495). The functional results were similar between the two groups. CRT did not improve long-term oncological outcomes in patients with LA upper rectal adenocarcinoma, but increased postoperative complications compared with US.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer.

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL). A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire. A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups. Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

New Anastomosis Technique to Prevent Anastomotic Leakage in Laparoscopic Anterior Resection for Rectal Cancer, Especially Upper Rectal Cancer.

Anastomotic leakage (AL) is a major problem in rectal cancer surgery. To prevent AL, we developed a side-to-side anastomosis technique using a circular stapler and termed it the circular side stapling technique (CST). We herein report the method and outcome of the CST. In this study, we analyzed 154 patients with stage 0 to III rectal cancer who underwent curative laparoscopic low anterior resection. Perioperative factors and complications were compared between the CST and usual double stapling technique (DST). The CST was performed in 110 of the 154 patients. When comparing the outcomes of patients with upper rectal cancer. AL occurred in no patients in the CST group and in three patients in the DST group (p=0.011). The CST prevented AL in all patients with upper rectal cancer. The CST is a safe and useful procedure in laparoscopic anterior resection. This technique can prevent AL, especially in patients with upper rectal cancer.

Outcomes of anterior resection after laparoscopic and open surgery

Background The introduction of the laparoscope has improved the feasibility and patient health, owing to being a less invasive procedure. The use of a laparoscope for colorectal cancer surgery was debatable for fear of recurrence, tumor spillage, and nonradical tumor excision. However, the tendency for using laparoscopy in colorectal cancer surgery is in favor nowadays. Aim The aim was to compare the results of laparoscopic and open surgical techniques in colorectal cancer located in the rectosigmoid region. Patients and methods This prospective study included 50 patients with upper rectal cancer attending the outpatient clinic of Ain Shams University Hospitals, who were treated over a 3-year period. Patients underwent anterior resection either by open technique (first group) or using laparoscopy (second group). Comparative items included operative events (time, blood loss, efficacy of tumor resection, etc.), early postoperative complications (wound infection, anastomotic leakage, etc.), and late postoperative complications (stricture and local recurrence). Results This study shows no significant difference between the two groups regarding length of specimen, safety margins, number of retrieved lymph nodes, tumor recurrence, or mortality. However, it shows significantly longer procedure, less blood loss, and less wound complications in the laparoscopic group. Conclusion Both laparoscopic and open procedures for rectal cancer surgeries can achieve the same radical resection; however, wound complications seemingly are more frequent in cases having open colorectal resections. The time consumption problem of advanced laparoscopic surgery will improve by gaining more experience and using the best equipment.

Does preoperative chemoradiotherapy improve the results of treatment upper rectal cancer?

Does preoperative chemoradiotherapy improve the results of treatment upper rectal cancer?

Preoperative T staging of colon cancer using CT colonography with multiplanar reconstruction: new diagnostic criteria based on "bordering vessels".

Preoperative T staging of colon cancer, in particular, for distinguishing T3 from T2 and T4, has been a challenge. The aim of this study was to evaluate newly developed criteria for preoperative T staging of colorectal cancer using computed tomography colonography (CTC) with multiplanar reconstruction (MPR), based on the spatial relationship of tumors and "bordering vessels," that is, marginal vessels that are detectable by multi-detector row CT with MPR. A total of 172 patients with colon and upper rectal cancer who underwent preoperative CTC and surgery between August 2011 and September 2013 were included. Preoperative T staging using the new criteria was performed prospectively and compared with pathologic results. Sensitivity, specificity, and accuracy of T staging by CTC using the new criteria were 63%, 80%, and 77% for T2 (n = 30); 72%, 94%, and 81% for T3 (n = 95); and 79%, 99%, and 97% for T4a (n = 14), respectively. Positive predictive value for T3 was 93%, indicating that a T3 diagnosis by CTC is precise. In addition, negative predictive value for pathological T4a was 98%, indicating that a "not T4a" diagnosis by CTC is also precise. Our newly developed criteria are useful for preoperative T staging, particularly for distinguishing T3 from T2 and T4.

Comparison of efficacy and safety of preoperative Chemoradiotherapy in locally advanced upper and middle/lower rectal cancer

BackgroundWe aimed to explore the efficacy and safety profile of preoperative neoadjuvant chemoradiation (NACRT) in locally advanced rectal cancer (LARC) in upper rectum versus middle/lower rectum.MethodsThe study included 173 patients with stage II or III (T2-4b, N0-2b) LARC who underwent NACRT followed by total mesorectal excision (TME) between January 2011 and October 2016. Cox regression, log-rank test, and Kaplan–Meier curves were calculated.ResultsAmong the 173 patients, 58 had lesions in the upper rectum and 115 patients had lesions in middle/lower rectum. In a median follow-up of 35 months (range, 6–73 months), the 5-year disease-free survival (DFS) and overall survival (OS) were 84% and 88% for the patients with upper rectal cancer and 77% and 68% for those with middle/lower rectal cancer (P = 0.251 and P = 0.058, respectively). The 5-year DFS (P = 0.012) and OS (P = 0.003) were better in the NACRT responders [tumor regression grade (TRG) 0 or 1] compared with nonresponders (TRG 2 or 3). The independent prognostic factor of favorable response to NACRT was the FOLFOX regimen (P = 0.004).ConclusionsPatients with LARC in the upper rectum who underwent NACRT followed by TME had similar DFS and a trend toward longer OS, compared with those who had middle/lower rectal lesions. Furthermore, FOLFOX may yield superior results than fluoropyrimidine based regimen during NACRT. NACRT might be an alternative option for patients with LARC in the upper rectum as it has a favorable pathological complete response rate and comparable clinical outcomes when compared with patients with LARC in middle/lower rectum.

Preoperative chemoradiation in upper rectal cancer: A retrospective analysis of our recent data

Objectives: Preoperative chemoradiotherapy (PCRT) is the standard treatment for locally advanced rectal cancer. Whether to apply this treatment for upper rectal cancer (URC) is nowadays questioned, considering greater toxicity in this setting. Our objective was to retrospectively analyze the outcomes in patients with URC that underwent PCRT.

Marked edema of colonic stoma after colectomy and severe pulmonary hypertension: Report of two cases

Pulmonary hypertension (PH) is a disease with a poor prognosis and is a risk for perioperative heart and respiratory failure. Few reports exist regarding a colectomy performed in patients with PH. Herein, we report two cases of colectomy performed in patients with severe PH, accompanied with marked edema of the colonic stoma after surgery. In case 1, a 54-year-old patient with sigmoid cancer and severe primary PH underwent Hartmann's operation. After the operation, his stoma became markedly edematous and ulcerated. Swelling of the stoma became gradually reduced, and the patient was discharged from hospital 36 days after the operation. In case 2, a 62-year-old patient with upper rectal cancer and severe PH also underwent Hartmann's operation; his stoma became markedly edematous without ulceration. Marked edema of the colonic stoma was observed in two cases with severe PH, with ulceration of the mucosa observed in one case. It was considered reasonable to avoid anastomosis in cases with severe PH.

Long-term outcomes after Natural Orifice Specimen Extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study.

PurposeThe aim of this study was to compare the long-term outcomes of total laparoscopic surgery with Natural Orifice Specimen Extraction (NOSE) with those for conventional laparoscopy (CL)-assisted surgery for treating rectal cancers.MethodsWe reviewed the prospectively collected records of 844 patients (163 NOSE and 681 CL) who underwent curative surgery for mid- or upper rectal cancers from January 2006 to November 2012. We applied propensity score analyses and compared oncological outcomes for the NOSE and CL groups in a 1:1 matched cohort.ResultsAfter propensity score matching, each group included 138 patients; the NOSE and CL groups did not differ significantly in terms of baseline clinical characteristics. The median follow-up was 57.7 months (interquartile range, 42.4–82.5 months). The combined 5-year local recurrence rate for all tumor stages was 4.1% (95% confidence interval [CI], 0.9%–7.4%) in the NOSE group and 3.0% (95% CI, 0%–6.3%) in the CL group (P = 0.355). The combined 5-year disease-free survival rates for all stages were 89.3% (95% CI, 84.3%–94.3%) in the NOSE group and 87.3% (95% CI, 81.8%–92.9%) in the CL group (P = 0.639). The postoperative mean fecal incontinence scores at 6, 12, and 24 months were similar between the 2 groups.ConclusionIn our experience, NOSE for mid- and upper rectal cancer had acceptable long-term oncologic outcomes comparable to those of conventional minimal invasive surgery and seems to be a safe alternative to reduce access trauma.

Lateral lymph node metastasis in a patient with T1 upper rectal cancer treated by lateral lymph node dissection: a case report and brief literature review

BackgroundLateral lymph node (LLN) metastasis may occur in patients with advanced rectal cancers of which the lower margins are located at or below the peritoneal reflection. However, LLN metastasis from a T1 rectal cancer is rare. Here, we report a case of LLN metastasis from a T1 upper rectal cancer that was successfully treated by sequential LLN dissection.Case presentationA 56-year-old man was referred to our hospital for the treatment of a T1 upper rectal cancer. We performed a laparoscopic low anterior resection. Histological examination showed a moderately differentiated adenocarcinoma with submucosal layer invasion; the invasion depth was classified as head invasion, without vessel or lymph duct invasion. Tumor budding was classified as grade 1. A total of six lymph nodes were harvested, and no lymph node metastases were detected. The postoperative course was uneventful. At 6 months after surgery, however, the serum carcinoembryonic antigen levels were elevated, and abdominal computed tomography (CT) revealed swollen lymph nodes in the right internal and common iliac artery area. Positron emission tomography with CT revealed hot spots in the same lesions. A retrospective re-evaluation of the preoperative CT images revealed no apparent swollen lymph nodes; however, an unusual soft tissue area was detected around the right internal iliac artery. A right LLN dissection was performed. Fifteen lymph nodes were resected, and histologically, metastases of adenocarcinoma were identified in 3 nodes. The postoperative course was again uneventful. The patient was given 12 cycles of adjuvant chemotherapy with FOLFOX (fluorouracil, leucovorin, and oxaliplatin). The patient remains healthy and with no signs of recurrence at 30 months after the second surgery.ConclusionsLLN metastasis occurs very rarely in patients with T1 upper rectal cancer and no risk factors for lymph node metastasis; however, a careful perioperative examination of the LLN should be performed. In cases involving LLN metastasis, a LLN dissection may be a therapeutic option if performed with curative intent.

Value of multi-disciplinary input into laparoscopic management of rectal cancer - An observational study.

AIMTo assess the impact of multi-disciplinary teams (MDTs) management in optimising the outcome for rectal cancers.METHODSWe undertook a retrospective review of a prospectively maintained database of patients with rectal cancers (defined as tumours ≤ 15 cm from anal verge) discussed at our MDT between Jan 2008 and Jan 2011. The data was validated against the national database to ensure completeness of dataset. The clinical course and follow-up data was validated using the institution’s electronic patient records. The data was analysed in terms of frequencies and percentages. Significance of any differences were analysed using χ2 test. A Kaplan-Meier analysis was performed for overall survival and disease free survival.RESULTSFollowing appropriate staging, one hundred and thirty-three patients were suitable for potentially curative resections. Seventy two (54%) were upper rectal cancer (URC) - tumour was > 6 cm from the anal verge and 61 (46%) were lower rectal cancers (LRC) - lower extent of the tumour was palpable ≤ 6 cm. Circumferential resection margin (CRM) appeared threatened on pre-operative MRI in 19/61 (31%) patients with LRC requiring neo-adjuvant therapy (NAT). Of the 133 resections, 118 (89%) were attempted laparoscopically (5% conversion rate). CRM was positive in 9 (6.7%) patients; Median lymph node harvest was 12 (2-37). Major complications occurred in 8 (6%) patients. Median follow-up was 53 mo (0-82). The 90-d mortality was 2 (1.5%). Over the follow-up period, disease related mortality was 11 (8.2%) and overall mortality was 39 (29.3%). Four (3%) patients had local recurrence and 22 (16.5%) patients had distant metastases.CONCLUSIONManagement of rectal cancers can be optimized with multi-disciplinary input to attain acceptable long-term oncological outcomes even when incorporating a laparoscopic approach to rectal cancer resection.

Adjuvant treatment may benefit patients with high-risk upper rectal cancer: A nomogram and recursive partitioning analysis of 547 patients.

PurposeThe role of adjuvant chemoradiotherapy (ACRT) or adjuvant chemotherapy (ACT) in treating patients with locally advanced upper rectal cancer (URC) after total mesorectal excision (TME) surgery remains unclear. We developed a clinical nomogram and a recursive partitioning analysis (RPA)-based risk stratification system for predicting 5-year cancer-specific survival (CSS) to determine whether these individuals require ACRT or ACT.Materials and MethodsThis retrospective analysis included 547 patients with primary URC. A nomogram was developed based on the Cox regression model. The performance of the model was assessed by concordance index (C-index) and calibration curve in internal validation with bootstrapping. RPA stratified patients into risk groups based on their tumor characteristics.ResultsFive independent prognostic factors (age, preoperative increased carcinoembryonic antigen and carcinoma antigen 19-9, positive lymph node [PLN] number, tumor deposit [TD], pathological T classification) were identified and entered into the predictive nomogram. The bootstrap-corrected C-index was 0.757. RPA stratification of the three prognostic groups showed obviously different prognosis. Only the high-risk group (patients with PLN ≤ 6 and TD, or PLN > 6) benefited from ACRT plus ACT when compared with surgery followed by ACRT or ACT, and surgery alone (5-year CSS: 70.8% vs. 57.8% vs. 15.6%, P < 0.001).ConclusionsOur nomogram predicts 5-year CSS after TME surgery for locally advanced rectal cancer and RPA-based stratification indicates that ACRT plus ACT post-surgery may be an important treatment plan with potentially significant survival advantages in high-risk URC. This may help to select candidates of adjuvant treatment in prospective studies.

Long-Term Survival and Local Relapse Following Surgery Without Radiotherapy for Locally Advanced Upper Rectal Cancer: An International Multi-Institutional Study.

Controversy remains regarding whether preoperative chemoradiation protocol should be applied uniformly to all rectal cancer patients regardless of tumor height. This pooled analysis was designed to evaluate whether preoperative chemoradiation can be safely omitted in higher rectal cancer.An international consortium of 7 institutions was established. A review of the database that was collected from January 2004 to May 2008 identified a series of 2102 patients with stage II/III rectal or sigmoid cancer (control arm) without concurrent chemoradiation. Data regarding patient demographics, recurrence pattern, and oncological outcomes were analyzed. The primary end point was the 5-year local recurrence rate.The local relapse rate of the sigmoid colon cancer (SC) and upper rectal cancer (UR) cohorts was significantly lower than that of the mid/low rectal cancer group (M-LR), with 5-year estimates of 2.5% for the SC group, 3.5% for the UR group, and 11.1% for the M-LR group, respectively. A multivariate analysis showed that tumor depth, nodal metastasis, venous invasion, and lower tumor level were strongly associated with local recurrence. The cumulative incidence rate of local failure was 90.6%, 92.5%, and 94.4% for tumors located within 5, 7, and 9 cm from the anal verge, respectively.Routine use of preoperative chemoradiation for stage II/III rectal tumors located more than 8 to 9 cm above the anal verge would be excessive. The integration of a more individualized approach focused on systemic control is warranted to improve survival in patients with upper rectal cancer.

Отдаленные результаты хирургического и комбинированного лечения больных раком верхнеампулярного отдела прямой кишки

Background. Сomparative assessment of long-term oncologic outcomes of surgical and combined treatment of patients with upper rectal cancer. Materials and methods. Patients aged &gt; 18 with histologycally verified upper T1–4N0–2M0 rectal cancer were included. In group A patients received neoadjuvant chemoradiotherapy 25 Gy in 5 Gy fractions with capecitabine 850 mg/m2 bid per os on radiation days and surgery. In group B patients received surgery alone. Results. From january 2004 to december 2014, we selected 227 archival cases of patients with upper rectal cancer. Group A was 103 patients (45.4 %) in group B – 123 (54.6 %). We traced long-term results of treatment in 217 (96.6 %) patients. In the group A was 98 (95.1 %) patients, in the group B – 119 (96.7 %) patients. Local recurrence occurred in group A – 1 (1.2 %) patient, in group B – 3 (2.5 %) patients (p = 0.413). The frequency of distant metastases developed in group A in 10 (10.2 %) patients and in group B – 15 (12.6 %) patients (p = 0.581). Overall survival in group A was 90.6 %, and the disease-free survival – 89.6 %, in group B – 82.8 % and 81.9 %, respectively (p = 0.46). Conclusions. Surgical treatment of patients with upper rectal cancer stage I–III, in compliance with all oncological principles is justified.

Longterm –ostomy as a quality marker: Comparison of outcomes from a six year series of laparoscopic surgery in MRI defined low rectal cancer

AimWe propose long-term -ostomy rate following laparoscopic rectal cancer resection must be included as an overall quality indicator of treatment in conjunction with frequently reported and readily available end points. MethodA database was collated prospectively of consecutive rectal cancer resections over a 6-year period. Recorded data included pre-operative MRI (tumour stage and height from the anal-verge), as well as demographics, treatment, local recurrence rate, survival and -ostomy rate as the primary outcome measure. Results65 patients were identified and classified as low-rectal cancer if the tumour on MRI was < 6 cm from the anal verge or middle/upper-rectal cancer if between 6 and 15 cm from the anal-verge and below the peritoneal reflection. Permanent stoma rates including colostomies and non-reversed ileostomies were 31.7% for middle/upper rectal cancer; 62.5% for low-rectal cancer and an overall rate of 42.1% for all rectal cancers. For upper-rectal cancer the rates of local recurrence, predicted mortality, R0 resection and conversion were: 0%, 1.9%, 97.6% and 0% respectively. Corresponding figures for low-rectal cancer were: 4.2%, 2.7%, 95.8% and 0%. There were no significant differences for age, sex, predicted morbidity/mortality, survival, recurrence or leak rates between the groups. ConclusionLaparoscopic rectal cancer surgery has a comparable permanent -ostomy rate to open rectal cancer surgery. We benchmark 31.7% as the permanent -ostomy rate for upper-rectal cancer and 62.5% for low-rectal cancer following laparoscopic resection, in the context of 96.9% R0 resection and 0% conversion rate in a consecutive series of patients.

2115 The role of adjuvant chemotherapy in patients with stage II/III upper-rectal cancer

2115 The role of adjuvant chemotherapy in patients with stage II/III upper-rectal cancer

2053 Nomogram and recursive partitioning analysis to determine the risk of cancer-specific survival for patients with stage II or III upper rectal cancer after radical surgery

2053 Nomogram and recursive partitioning analysis to determine the risk of cancer-specific survival for patients with stage II or III upper rectal cancer after radical surgery