Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence (original) (raw)
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Journal of Turkish Association of Colorectal Surgeons, 2011
Background After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence. Methods A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics. Results In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p=0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p=0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p<0.001) for the two groups. Conclusion This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.
Journal of Surgical Oncology, 2000
Background and Objectives: The incidence of locoregional recurrences (LR) following radical surgery of rectal cancer varies from 5% to 30% according to the literature. The purpose of this prospective study was to compare the outcome of the Abdomino-Perineal Excision (APE) vs. the Anterior Resection (AR) in a consecutive series of 188 patients who underwent surgery for cure from 1980 to the end of 1992 (81 APE and 107 AR), followed for 5 years, evaluating their influence on the incidence of the recurrences. Methods: The patients were enrolled at random in the two surgical groups, provided that a radical excision of the tumour, with only two limits: the level of the lesion from the anal verge and the presence of a severe incontinence instrumentally proven. TNM, Dukes staging, grading, and tumour location were statistically evaluated. Further primary suture vs. packing of the perineal wound in APE and handsewn vs. stapled anastomosis in AR were compared in relation with the incidence of LR. Results: The overall local recurrence rate was 19.2% (32/167), in details 19.7% for APE and 18.5% for AR. Similar recurrence rates were observed following both procedures, matching the patients according to the Dukes stage and different details of techniques. A slight statistically significant difference was found as far as the tumour location is concerned in the group treated with anterior resection (p ס <0.05) because of the higher recurrence observed in AR performed for tumours of the lower third of the rectum in comparison with the more proximal level. Conclusions: The AA conclude that the choice of the right surgical procedure in the rectal carcinoma depends on the characteristics of the tumour and the conditions of the patients, provided that the oncologic indications were respected, because recurrence and survival rate are independent from the surgical approaches.
Abdominoperineal Resections for Rectal Cancer: Reducing the Risk of Local Recurrence
Seminars in Colon and Rectal Surgery, 2010
Treatment of patients with distal and locally advanced rectal cancer is challenging. In many series, abdominoperineal resection for distal rectal cancer is related to a high percentage of local recurrences. Some authors relate this high percentage of local recurrence to the abdominoperineal resection itself, considering it to be a poor operation for distal rectal cancer, while other authors relate it to technically inadequate resections: a high incidence of positive circumferential resection margins is seen because of coning of the specimen when the mesorectal fascia is followed or because of inadvertent perforation of the rectal wall. In many other series an acceptable low percentage of local recurrence after abdominoperineal resection is reported. These authors have consistently advocated a wide perineal resection, resecting the levator ani muscle en bloc with the specimen. These enhanced perineal resections are not standardized in the surgical world. We reviewed the literature and describe technical considerations for performing the perineal phase in abdominoperineal resection to reduce circumferential resection margin positivity and local recurrence rates. Semin Colon Rectal Surg 21:81-86
Local recurrence following total mesorectal excision for rectal cancer
British Journal of Surgery, 1996
Early results after rectal cancer surgery in a defined population were compared before and after the introduction of total mesorectal excision. In the first period (1984–1986) 211 cases of rectal cancer were diagnosed and in the second (1990–1992) 230. Of these, 134 patients in the first period (group 1) had anterior resection or abdominoperineal excision which was considered curative. In the second period 128 curative anterior resections and abdominoperineal excisions were performed by a limited number of surgeons familiar with total mesorectal excision (group 2). No differences between the groups were found in stage distribution, rate of curative operations, postoperative complications or postoperative mortality. Local recurrence had developed in 19 patients in group 1 and in eight in group 2, 1 year after the end of the study periods (P = 0·03). Local radicality was in doubt in 13 patients in group 1 and in eight in group 2. In the remaining 121 and 120 patients, 13 and four loca...
The surgical approach to locally recurrent rectal cancer
Techniques in Coloproctology, 2004
The incidence of rectal cancer recurrence after surgery is 5-45%. Predictive factors relating to local recurrence (LR) are the surgical experience, the location of the tumour, the tumour's pathology, the circumferential margins, the successful total mesorectal excision (TME) and the use of radiochemotherapy. The use of TME and preoperative radiotherapy reduce the risk of LR. Diagnosis is done using imaging techniques. Computed tomography with rectal contrast is the preferred imaging technique. The surgical strategy for LR at and around a previous anastomosis is the resection of the anastomosis with a sphincter-saving procedure. LR isolated to one side after anterior resection is an indication for en bloc resection of the rectum with a portion of the bladder. LR fixed to the sacrum requires a composite abdominosacral resection. Extrapelvic disease is a contraindication to curative resection. The composite sacropelvic resection is a reasonable alternative to palliative radiation with long-term survival of 20-30%.
Anterior Resection for Rectal Cancer With Mesorectal Excision
Annals of Surgery, 2004
Objective: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4-to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. Summary Background Data: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. Methods: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. Results: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P Ͻ 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. Conclusions: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.
Journal of Surgery, 2016
Total mesorectal excision (TME) has emerged as a method for complete cure of rectal cancer with promising results. The present study aimed to evaluate the technical feasibility and the clinical and oncological outcomes of laparoscopic TME with abdominoperineal resection (APR) for distal rectal carcinoma. Twenty patients with distal rectal carcinoma were treated with laparoscopic APR and TME in the period of January 2012 to March 2015. Patients' demographics, clinical symptoms, operation time, complications, pathological characteristics of the rectal tumor, and the local and distant recurrence of the tumor were recorded and analyzed. The study included 11 (55%) female and 9 (45%) male of a mean age of 46.9 ± 10.8 years. The mean distance of the tumor from the anal verge was 3.35 ± 0.9 cm. The mean operation time was 182 ± 7 minutes. Adenocarcinoma accounted for 55% of cases, whereas mucinous adenocarcinoma was detected in 40% of patients, and signet ring carcinoma in 5%. The mean circumferential resection margin (CRM) was 4.6 ±3.5 mm. The mean duration of hospital stay was 9.21± 6.9 days. Perioperative complications were recorded in seven patients (35%). Five (25%) cases were converted to open surgery. The median follow-up duration was 18 months. Local recurrence was diagnosed in two (10%) cases. Laparoscopic TME is a technically feasible procedure, yet requires adequate training and sufficient knowledge of the anatomy of the pelvis. Although all patients underwent APR and 90% of them received neoadjuvant treatment; the local recurrence was still higher than other studies which can be attributed to the pathologic characters and the stage of the tumors.
International Journal of Colorectal Disease, 2018
Background Extralevator abdominoperineal excision (ELAPE) probably improves the oncological quality of low rectal cancer surgery, as compared to standard abdominoperineal excision (SAPE), possibly due to lower rates of accidental perioperative bowel perforations and lower rates of circumferential resection margin (CRM) positivity. The procedure may however, increase post-operative morbidity. The aim of this paper was to compare outcomes of SAPE and ELAPE for carcinoma of the lower rectum. Methods This is a retrospective study of patients operated on at a single colorectal unit, in a provincial hospital in Denmark. Consecutive patients undergoing abdominoperineal excision (APE) between 2006 and 2012 were included. During this period, a gradual paradigm shift occurred towards adopting ELAPE, although both procedures were performed without a clear selection strategy. We reviewed medical records, including the pathological and radiological data. Patients were divided into two groups, SAPE and ELAPE. Main endpoints were rates of positive CRM, intraoperative bowel perforations, local recurrence rate, length of hospital stay, operative time, and perineal woundrelated complications. Results One hundred and seven patients were included (median age 68 years, range 42-88 years; men = 72). The SAPE group included 39 patients and the ELAPE group 68 patients. Intraoperative bowel perforation was significantly lower in the ELAPE group (20.5 % SAPE vs 7.4 % EL-APE, p = 0.045). The rate of positive CRM was not significantly different (2.6 % SAPE vs 7.4 % ELAPE, p = 0.413). The local recurrence rate was not statistically significant (17.9 % SAPE vs 13.2 % ELAPE, p = 0.513). In the ELAPE group, operative time and hospital stay were significantly longer than the SAPE group (p = 0.001 and p = 0.021, respectively). Conclusions We found low rates of positive CRM after APE compared with the literature. ELAPE did not reduce these rates, and although the local recurrence rate was lower, this did not reach statistical significance. ELAPE has significantly reduced the rate of intraoperative bowel perforation and can optimize low rectal cancer surgery in selected patients. We found no significant differences between the two procedures regarding wound-related complications. A tailored approach and a larger trial with longer follow-up are needed to evaluate long-term results.