Treatment of advanced rectal cancers: Cylindrical abdominoperineal excision of rectum (original) (raw)
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Prilozi - Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski nauki, 2022
Aim: To evaluate the effect of extralevator abdominoperineal excision of the rectum (ELAPE) on the circumferential resection margin (CRM) and overall survival in comparison to standard abdominoperineal excision of the rectum (APE) in patients with advanced rectal cancer. Material and Methods: This retrospective study encompasses patients with advanced rectal cancer operated on with two different methods: prone Jack-Knife position ELAPE and APE. In part of them, neoadjuvant chemoradiation was conducted. Postoperative patient, tumor, and outcome data were analyzed in terms of differences in CRM positivity and overall survival. Results: Of 67 patients treated with either APE (52) or ELAPE (15), 43 were male and 24 were female. Neoadjuvant treatment was conducted on 49 of the total patients. Complete pathological response (T0) was achieved in 3 patients. Positive CRM was reported in 7 patients (11.5 %), 3 in ELAPE and 4 in APE group (p = 0.348). The overall postoperative complication rate was 56.7%. Mean survival period was 42.2 months. Overall survival rate for both groups was 67.2 %. No statistical differences were seen between the ELAPE and APE procedure in terms of overall survival (p = 0.483). Conclusions: Differences between the use of ELAPE and APE in terms of CRM positivity and overall survival were not statistically significant. Therefore, we conclude that ELAPE is not superior to standard APE in the treatment of advanced rectal cancer.
Journal of the Egyptian National Cancer Institute, 2013
Introduction: This study aimed to investigate local control and survival rates following abdominoperineal resection (APR) compared with low anterior resection (LAR) in lower and middle rectal cancer. Methods: In this retrospective study, 153 patients with newly histologically proven rectal adenocarcinoma located at low and middle third that were treated between 2004 and 2010 at a tertiary hospital. The tumors were pathologically staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. Surgery was applied for 138 (90%) of the patients, of which 96 (70%) underwent LAR and 42 were (30%) treated with APR. Total mesorectal excision was performed for all patients. In addition, 125 patients (82%) received concurrent (neoadjuvant, adjuvant or palliative) pelvic chemoradiation, and 134 patients (88%) received neoadjuvant, adjuvant or concurrent chemotherapy. Patients' follow-up ranged from 4 to 156 (median 37) months. Results: Of 153 patients, 89 were men and 64 were women with a median age of 57 years. One
Diseases of The Colon & Rectum, 2004
PURPOSE: This study was designed to examine the outcome of cancer of the lower rectum, particularly the rates of local recurrence and survival for tumors located in this area that have been treated by anterior or abdominoperineal resections. METHODS: A prospective, observational, national, cohort study which is part of the Norwegian Rectal Cancer Project. The present cohort includes all patients undergoing total mesorectal excision in 47 hospitals during the period November 1993 to December 1999. A total of 2,136 patients with rectal cancer within 12 cm of the anal verge were analyzed; there were 1,315 (62 percent) anterior resections and 821 (38 percent) abdominoperineal resections. The lower edge of the tumor was located 0 to 5 cm from the anal verge in 791 patients, 6 to 8 cm in 558 patients, and 9 to 12 cm in 787 patients. According to the TNM classification, there were 33 percent Stage I, 35 percent Stage II, and 32 percent Stage III. RESULTS: Univariate analyses: The five-year local recurrence rate was 15 percent in the lower level, 13 percent in the intermediate level, and 9 percent in the upper level (P = 0.014). It was 10 percent local recurrence after anterior resection and 15 percent after abdominoperineal resection (P = 0.008). The five-year survival rate was 59 percent in the lower level, 62 percent in the intermediate level, and 69 percent in the upper level (P < 0.001), respectively, and it was 68 percent in the anterior-resection group and 55 percent in the abdominoperineal-resection group (P < 0.001). Multivariate analyses: The level of the tumor influenced the risk of local recurrence (hazard ratio, 1.8; 95 percent confidence interval, 1.1–2.3), but the operative procedure, anterior resection vs. abdominoperineal resection, did not (hazard ratio, 1.2; 95 percent confidence interval, 0.7–1.8). On the contrary, operative procedure influenced survival (hazard ratio, 1.3; 95 percent confidence interval, 1–1.6), but tumor level did not (hazard ratio, 1.1; 95 percent confidence interval, 0.9–1.5). In addition to patient and tumor characteristics (T4 tumors), intraoperative bowel perforation and tumor involvement of the circumferential margin were identified as significant prognostic factors, which were more common in the lower rectum, explaining the inferior prognosis for tumors in this region. CONCLUSIONS: T4 tumors, R1 resections, and/or intraoperative perforation of the tumor or bowel wall are main features of low rectal cancers, causing inferior oncologic outcomes for tumors in this area. If surgery is optimized, preventing intraoperative perforation and involvement of the circumferential resection margin, the prognosis for cancers of the lower rectum seems not to be inherently different from that for tumors at higher levels. In that case, the level of the tumor or the type of resection will not be indicators for selecting patients for radiotherapy.
Surgical resection for rectal cancer: a gold standard or a last resort
In recent times, the management of rectal cancer has evolved and a multimodal approach utilising selective combinations of chemotherapy, radiotherapy and surgery are employed. Surgery may be local excision or proctectomy which in turn can be open, laparoscopic or robotic. Improvement in neoadjuvant treatment has demonstrated that some patients ultimately do not need to undergo surgery or may only require local excision of their tumour. However, this is a complex field where many treatment options exist and selecting the correct approach is reliant on accurate pre-operative staging and then tailoring treatments to each individual patient. It is imperative that patients are informed of the advantages and disadvantages of each approach allowing them to make an informed decision based on the evidence. It is also crucial that in treating rectal cancer, the surgical team has all these tools in their armamentarium in order to treat all stages of the disease. In the present case, the patient underwent maximal neoadjuvant treatment with chemotherapy and chemoradiotherapy and ultimately required pelvic exenteration. The decision making in this process is truly multidisciplinary and requires many specialties and allied health teams to support the patient through this process.
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 Coloproctology, 2013
Introduction: the standard treatment for locally advanced extra-peritoneal rectal adenocarcinoma, consists of neoadjuvant treatment with radiotherapy and chemotherapy followed by total mesorectal excision. Objective: evaluate, retrospectively, the patients submitted to neoadjuvant therapy and surgery that presents with total remission of the lesion in the anatomopathological examination. Methods: between 2000 and 2010, 212 patients underwent surgery at the Coloproctology Unit at DMAD at FCM–UNICAMP. They were grouped as: rectosigmoidectomy and colorectal anastomosis (n = 54), rectosigmoidectomy with coloanal anastomosis (n = 41), 114 abdominoperineal resection of the rectum (n = 114) and other (n = 3). Results: thirty (14.2%) patients (mean age 57.6 years; 60% males) showed complete remission of the rectal lesion. 4 (13.3%) had compromised lymph nodes and/or lymphatic invasionAt follow-up (mean 51.9 months), 4 (13.3%) presented with local recurrence (one patient) or distant metastas...
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.
Surgical Treatment of Rectal Cancer: State of the Art and Future Perspectives
European Surgery-Acta Chirurgica Austriaca, 2002
Background: Surgical management is the primary treatment of potentially curable rectal cancer. In most cases, this involves resection of the primary tumour and regional lymph nodes. However, treatment of rectal cancer patients may vary from local excision in carefully selected patients with limited carcinomas to multimodality management for advanced rectal cancers. The objective in all cases is to maximize both oncological and functional results. The purpose of this article is to provide an overview of state of the art surgical treatment of primary rectal cancer as well as a discussion of selected current controversies. Methods: Extent of resection, operative techniques such as Io-caI excision, coloanal anastomosis with or without a colonic pouch reservoir, need for a defunctioning colostomy, laparoscopic rectal surgery, and quality of life after surgery for rectal cancer are discussed. Results: In rectal cancer patients, a total mesorectal excision is the standard procedure. A local excision may be performed for favourable TI c:mcers. Low or ultralow resections with coloanal anastomoses show the salne oncological results as abdominoperineal excisions. A colonic pouch significantly improves postoperative function in patients with sphinctersparing resections. However, postoperative sphincter function might he impaired and further studies are necessary to determine quality of life in these patients. Prospective studies should be perlk~lmed to compare ontological outcome after laparoscopic and open resections. Conclusions: Surgical treatment of rectal cancer depends on localization, extent, and histology of the tulnour. Preoperative education of patients and extensive discussion of potential postoperative problems are crucial for determining which patient benefits most from which type of surgery.
Changes in treatment of rectal cancer: increased use of low anterior resection
Techniques in Coloproctology, 2011
The most common surgical procedures for patients with rectal cancer are low anterior resection (LAR) or abdominoperineal excision (APE). The aim of the present study is to evaluate and report the changes in the incidence of LAR and APE in the surgical treatment of rectal cancer over the last 15 years in a single surgical department. The patient sample consisted of 251 consecutive patients (mean age 65.17; age range 22-87) that underwent surgical treatment for rectal cancer in a single center from 1996 to 2010. This time frame was divided into three 5-year periods (1996-2000, 2001-2005 and 2006-2010). Patients were classified into one of the aforementioned groups, depending on the date of their treatment. In the first period (1996-2000), 71 patients were treated for rectal cancer. Among them, 32.4% (n = 23) underwent an abdominoperineal excision (APE) while 56.3% (n = 40) were treated with LAR. In the second period (2001-2005), included 102 patients, from which 29.4% (n = 30) received an APE and 60.8% (n = 62) underwent a LAR for their disease. In the final period (2006-2010), from the 78 patients, only 12.8% (n = 10) of them underwent APE, while 74.3% (n = 58) were treated with LAR. There was a statistically significant (chi-square test, P = 0.005) difference between the 3 periods of time concerning the performance of LAR and APE. According to the results of the present study, the rates of APE seem to decrease during the last 15 years, while LAR is more widely used in the surgical treatment of rectal cancer.