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International Journal of Colorectal... Jun 2020Our study is the first meta-analysis to compare total mesorectal excision (TME) plus lateral lymph node dissection (LLND) with TME on rectal cancer patients regarding... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVE
Our study is the first meta-analysis to compare total mesorectal excision (TME) plus lateral lymph node dissection (LLND) with TME on rectal cancer patients regarding outcomes including overall survival, disease-free survival, local recurrence, complications, urinary dysfunction, and sexual dysfunction.
METHODS
PubMed, Embase, and Cochrane library were searched for publications up to October 2019. Two investigators independently screened the studies for eligibility and extracted specific data. Relevant data were analyzed by Review Manager version 5.3.
RESULTS
Patients in TME + LLND group suffered more complications (OR = 1.48, 95% CI [1.07, 2.03], P = 0.02) compared with TME group; no significant difference was observed in overall survival (HR = 1.11, 95% CI [0.77, 1.61], P = 0.57), disease-free survival (HR = 1.05, 95% CI [0.85, 1.30], P = 0.64), local recurrence (OR = 0.93, 95% CI [0.56, 1.54], P = 0.78), and urinary dysfunction (OR = 1.60, 95% CI [0.66, 3.87], P = 0.3).
CONCLUSION
TME + LLND may cause more complications compared with TME on rectal cancer patients. However, the definite conclusion still requires more researches.
Topics: Disease-Free Survival; Humans; Lymph Node Excision; Neoplasm Recurrence, Local; Postoperative Complications; Proctectomy; Rectal Neoplasms; Sexual Dysfunction, Physiological; Survival Rate; Urination Disorders
PubMed: 32356120
DOI: 10.1007/s00384-020-03610-1 -
Acta Chirurgica Belgica Oct 2020We aimed to compare the short-term surgical and early surgical oncological outcomes of abdominoperineal resection (APR) and extralevator APR (ELAPR) in patients with...
We aimed to compare the short-term surgical and early surgical oncological outcomes of abdominoperineal resection (APR) and extralevator APR (ELAPR) in patients with low rectal carcinoma that have received neoadjuvant chemoradiotherapy (NACRT), whose abdominal procedures were performed laparoscopically. One hundred and four patients who underwent APR or ELAPR for stage II/III low rectal carcinoma NACRT between 2013 and 2016 were evaluated by reviewing the standard charts for colorectal carcinoma. Median follow-up for patients in APR group was 56 months(24-67 months) and 52 months(27-64 months) for ELAPR group. The postoperative complication rates were higher in ELAPR than in APR (perineal wound infection 38% vs. 22.5%( = .03), perineal wound dehiscence 57% vs. 25%( = .01), persistent perineal pain 28.5% vs. 13%( = .01), urinary dysfunction 23% vs. 14.5%( = .02), reoperation 16.5% vs. 4.8%( = .03), respectively). Circumferential resection margin positivity, the number of lymph nodes dissected, and the rate of intra-operative perforation of the tumor were similar for both surgical techniques. Local recurrence rates at postoperative 2 years were also similar after APR and ELAPR (8% vs. 9.5%, = .2). We conclude that in the era of routinely used NACRT, ELAPR is not superior to conventional APR for stage II/III low rectal carcinomas. ELAPR is associated with increased morbidity and has no short-term surgical oncological advantage over APR.
Topics: Aged; Carcinoma; Chemoradiotherapy, Adjuvant; Female; Humans; Laparoscopy; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Postoperative Complications; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 31250735
DOI: 10.1080/00015458.2019.1634925 -
Chirurgia (Bucharest, Romania : 1990) Oct 2021The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative...
The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative and early postoperative aspects, in choosing the suitable technique performed by surgical teams with experience in both open and minimally invasive surgery (MIS). This is a retrospective study, conducted between 2008-2020. Two hundred thirty-three patients with APR performed for low rectal or anal cancer were included. The cohort was divided into two groups, depending on the surgical approach used: Minimally Invasive Surgery (laparoscopic and robotic procedures) and Open Surgery (OS). The perioperative characteristics were analyzed in order to identify the optimal approach and a possible selection criteria. We identified a high percentage of patients with a history of abdominal surgery in the open group (p = .0002). Intraoperative blood loss was significantly higher in the open group (p= .02), with an increased number of simultaneous resections (p = .041). The early postoperative outcome was marked by significantly lower morbidity in the MIS group (p = .005), with mortality recorded only in the open group (3 cases), in patients that associated severe comorbidities. The hystopathological results identified a significant number of patients with stage T2 in the MIS group (p= .037). Minimally invasive surgery provides a major advantage to APR, by avoiding an additional incision, the specimen being extracted through the perineal wound. The success of MIS APR seems to be assured by a good preoperative selection of the patients, alongside with experienced surgical teams in both open and minimally invasive rectal resections. The lack of conversion identified in robotic APR confirm the technical superiority over laparoscopic approach.
Topics: Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34749853
DOI: 10.21614/chirurgia.116.5.573 -
Chirurgia (Bucharest, Romania : 1990) Apr 2024In this editorial, the authors bring to the attention of surgeons a personal point of view with the intention of offering a series of anatomical arguments to explain the...
In this editorial, the authors bring to the attention of surgeons a personal point of view with the intention of offering a series of anatomical arguments to explain the high rate of functional complications following ultralow rectal resections, resections dominated by faecal incontinence of various intensities. Having as a starting point the anatomy of the pelvic floor and the posterior perineum, the authors are concerned with the functional outcomes of the sphincter-saving anterior rectal resection, regarding the low and ultralow resection. Technically, a conservative surgery for low rectal cancer has been currently performed. If 25 years ago the abdominoperineal resection was the gold standard for rectal cancer located under 7cm from the anal verge, nowadays the preservation of the anal canal as a partner for colon anastomosis has been accomplished. Progressively, from a desire to preserve the normal passage of stool into the anal canal, as anatomically and physiologically as possible, the distal limit of resection was lowered to 2-4 cm from the anal verge and ultra-low anastomoses were created, within the anal sphincter complex. The stated goal: keep the oncological safety standard and, at the same time, avoid definitive colostomy. Starting from the normal anatomy of the pelvic floor and the anorectal segment, the authors take a look at the alterations of the visceral, muscular, and nerve structures as a consequence of the low anterior resection and, particularly, the ultralow anterior resection. A significant degree of functional outcomes regarding defecation, with the onset of marked disabilities of anal continence, the major consequence being anal incontinence (30-70%), have been noticed. The authors go under review for the main anatomical and physiological changes that accompany anterior rectal resection. Thus, the following questions arise: what is the lower limit of resection to avoid total fecal incontinence? Is total incontinence a greater handicap than colostomy or is it not? The answers cannot be supported by solid arguments at this time, but the need to initiate future studies dedicated to this problem emerges.
Topics: Humans; Fecal Incontinence; Rectal Neoplasms; Proctectomy; Anal Canal; Treatment Outcome; Syndrome; Pelvic Floor; Anastomosis, Surgical; Perineum; Rectum; Risk Factors; Low Anterior Resection Syndrome
PubMed: 38743827
DOI: 10.21614/chirurgia.2024.v.119.i.2.p.125 -
International Journal of Colorectal... Apr 2021This study determined the risk factors associated with perineal wound complications (PWCs) and investigated their effect on overall survival in patients with rectal...
PURPOSE
This study determined the risk factors associated with perineal wound complications (PWCs) and investigated their effect on overall survival in patients with rectal cancer who underwent abdominoperineal resection (APR).
METHODS
The clinicopathologic and follow-up data of patients who underwent APR for primary rectal cancer between 1998 and 2018 were reviewed. PWCs were defined as any perineal wound that required surgical intervention, antibiotics, or delayed healing for more than 2 weeks. The primary objective was identifying the risk factors of PWC after APR. The effect of PWC on survival was also investigated as a secondary objective.
RESULTS
Two hundred and twenty patients were included in the final analyses and 49 had PWCs. An operative time of > 285 min (odds ratio: 2.440, 95% confidence interval (CI): 1.257-4.889) was found to be independently associated with PWCs. When the follow-up time was > 60 months, patients with PWCs had a significantly lower overall survival rate than patients without PWC (n = 156; mean over survival: 187 and 164 months in patients without and with PWCs, respectively; P = 0.045). Poor differentiation (hazard ratio (HR): 1.893, 95% CI: 1.127-3.179), lymph node metastasis (HR: 2.063, 95% CI: 1.228-3.467), and distant metastasis (HR: 3.046, 95% CI: 1.551-5.983) were associated with poor prognosis.
CONCLUSION
Prolonged operative time increases the risk of PWCs, and patients with PWCs have a lower long-term survival rate than patients without PWCs. Therefore, surgeons should aim to reduce the operative time to minimise the risk of PWC in patients undergoing APR for rectal cancer.
Topics: Humans; Perineum; Postoperative Complications; Proctectomy; Rectal Neoplasms; Retrospective Studies; Risk Factors
PubMed: 33528748
DOI: 10.1007/s00384-021-03840-x -
Journal of Laparoendoscopic & Advanced... Apr 2021It is unclear whether the supine or prone approach for abdominoperineal resection (APR) influences outcomes. In a retrospective study of patients with rectal cancer... (Comparative Study)
Comparative Study
It is unclear whether the supine or prone approach for abdominoperineal resection (APR) influences outcomes. In a retrospective study of patients with rectal cancer who underwent curative laparoscopic APR from 2005 to 2018, we compared perioperative data, postoperative outcomes, oncological outcomes, and survival between the two approaches. We recruited 123 patients (58 for the supine group and 65 for the prone group), with a median age of 72 (41-93) years. Mean follow-up was 67.4-45.7 months (28-169) in the supine group and 47.8-30.9 months (13-158) in the prone group ( = .026). Duration of surgery was longer in the prone group at 237 ± 52.3 minutes versus 210 ± 56.6 minutes in the supine group ( = .007). The incidence of tumor perforation during surgery was 9% in the supine group versus 3% in the prone group ( = .208). The incidence of perineal wound infection did not differ significantly between groups (supine 22% versus prone 20%, = .93). The mesorectum was incomplete in 25% cases in the supine group and 14% cases in the prone group ( = .175). Circumferential resection margin positivity was 21% in the supine group and 14% in the prone group ( = .374). Local and distant recurrence was higher in patients with adenocarcinoma in the supine group at 10% and 31% versus 4% and 17% in the prone group ( = .177). Overall survival was higher in the prone group: 4% of patients died due to disease progression compared with 24% in the supine group ( = .034). Our results suggest that morbidity is similar with both laparoscopic techniques, but long-term outcomes seem better with the prone approach.
Topics: Adenocarcinoma; Adult; Aged; Aged, 80 and over; Female; Humans; Laparoscopy; Male; Margins of Excision; Mesocolon; Middle Aged; Neoplasm Recurrence, Local; Perineum; Postoperative Period; Proctectomy; Prone Position; Rectal Neoplasms; Retrospective Studies; Supine Position; Treatment Outcome
PubMed: 33646052
DOI: 10.1089/lap.2020.0969 -
European Journal of Surgical Oncology :... Dec 2023Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on...
INTRODUCTION
Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on quality of life has never been formally assessed.
MATERIALS AND METHODS
Patients who underwent abdominoperineal resection for rectal cancer between 2014 and 2022 in two prospective multicenter trials were included. Primary outcome was defined as median overall scores or scores on functional and symptom scales of the following quality of life questionnaires: 5-level version of the 5-dimensional EuroQol, Short Form-36, and European Organization for Research and Treatment of Cancer QoL Questionnaire Colorectal cancer 29 and 30, Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7.
RESULTS
Questionnaires were available in 27 patients with a perineal hernia and 62 patients without a perineal hernia. The 5-dimensional EuroQol score was significantly lower in patients with a perineal hernia (83 vs 87, p = 0.048), which implies a reduced level of functioning. The median scores of pain-specific domains were significantly worse in patients with a perineal hernia as measured by the SF-36 (78 vs. 90, p = 0.006), the EORTC-CR29 (17 vs. 11, p=<0.001) and EORTC-C30 (17 vs. 0, p = 0.019). Also, significantly worse physical (73 vs. 100, p = 0.049) and emotional (83 vs. 100, p = 0.048) functioning based on EORTC-C30 was observed among those patients. Minimally important differences were found for role, physical and social functioning of the SF-36 and EORTC-C30. The urological function did not differ between the groups.
CONCLUSION
A symptomatic perineal hernia can significantly worsen quality of life on several domains, indicating the severity of this complication.
Topics: Humans; Quality of Life; Prospective Studies; Rectal Neoplasms; Proctectomy; Hernia; Surveys and Questionnaires
PubMed: 37839295
DOI: 10.1016/j.ejso.2023.107114 -
Journal of Visceral Surgery Dec 2021The most widely practiced (standard) treatment of non-metastatic rectal cancer is based on proctectomy with mesorectal excision (partial or total according to the...
The most widely practiced (standard) treatment of non-metastatic rectal cancer is based on proctectomy with mesorectal excision (partial or total according to the location of the tumor and commonly called TME). Surgery is preceded by CAP50-type chemoradiotherapy (capecitabineand 50 Grays radiation) and performed 6-8 weeks after the end of chemoradiotherapy. The development of new endoscopic, surgical, radiation-based and chemotherapeutic modalities leads surgeons to envisage customized treatment to find the best compromise between functional and oncologic results according to the locoregional extension of the tumor. Superficial lesions are amenable to transanal excision. T2-3 tumors<4cm are amenable to rectal preservation when neoadjuvant treatment obtains a complete response, allowing local excision or close surveillance. Intensification endocavitary radiotherapy and induction and consolidation chemotherapy regimens to avoid recourse to salvage abdomino-perineal resection (APR) are under investigation. For locally advanced rectal cancers (T3-4 and all N+ irrespective of T), the following scenarios can be envisaged: for initially resectable tumors (T3N0, T1-T3N+, circumferential resection margin>2mm), neoadjuvant chemotherapy alone aims to minimize the risk of local recurrence while avoiding the sequelae of radiotherapy. In case of initially non-resectable tumors (T4, circumferential resection margin<1mm), induction chemotherapy before chemoradiotherapy and consolidation chemotherapy after short course radiotherapy provide better results than standard treatment in terms of complete response and recurrence-free survival, and should be routinely proposed in this indication.
Topics: Chemoradiotherapy; Humans; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Proctectomy; Rectal Neoplasms; Salvage Therapy; Treatment Outcome
PubMed: 33926836
DOI: 10.1016/j.jviscsurg.2021.04.001 -
Surgery Mar 2023Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal...
BACKGROUND
Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined.
METHODS
We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods.
RESULTS
A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection.
CONCLUSION
In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival.
Topics: Humans; Treatment Outcome; Adenocarcinoma; Rectal Neoplasms; Digestive System Surgical Procedures; Proctectomy; Retrospective Studies; Neoplasm Staging
PubMed: 36273975
DOI: 10.1016/j.surg.2022.08.040 -
ANZ Journal of Surgery Nov 2022Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome...
BACKGROUND
Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome morbidity associated with perineal reconstruction. We reviewed outcomes for patients undergoing APR in a hospital that performs inferior gluteal artery myocutaneous (IGAM) island transposition flaps and primary closure (PC) for perineal reconstruction.
METHODS
A retrospective study of patients who underwent APR for malignancy between January 2012 and March 2020 was performed and outcomes between IGAM reconstruction and PC compared. Primary outcomes were wound infection and dehiscence. Secondary outcomes included return to theatre, operative time, length of stay, flap loss and perineal hernia incidence.
RESULTS
One-hundred and two patients underwent APR, with 50 (49%) who had PC and 52 (51%) had IGAM flap reconstructions. There were no differences between each group with regards to wound infection (23 vs. 22%, P = 0.55) or wound dehiscence (25 vs. 24%, P = 0.92). Thirteen (25%) IGAM patients required a return to theatre compared to three PC patients (6%) (P = 0.008). IGAM procedures required twice the overall operative time (506 vs. 240 min, P = 0.001) with no differences between groups when comparing the APR component (250 vs. 240 min, P = 0.225). The IGAM group had a longer length of stay (median 13 days vs. 9 days, P = 0.001). Only one IGAM flap was lost and no symptomatic hernias were identified.
CONCLUSION
Perineal closure technique did not affect the incidence of wound infection or dehiscence. Closure technique should be tailored to underlying patient characteristics and surgical pathology.
Topics: Humans; Arteries; Myocutaneous Flap; Perineum; Postoperative Complications; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Retrospective Studies; Wound Infection
PubMed: 35604223
DOI: 10.1111/ans.17769