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Could the surgeon trust to radiotherapy help in rectal cancer?  [PDF]
Valentini V.,Gambacorta M.A.,Barba M.C.
Acta Chirurgica Iugoslavica , 2008, DOI: 10.2298/aci0803055v
Abstract: When the surgeon analyzes the ongoing literature on the evidence of the neoadjuvant approaches to rectal cancer finds a true paradox: from one side they seem to offer a relative less relevant contribute through the time, in fact whereas in the Swedish trial preoperative radiation yielded a significant improvement of local control and survival, after the introduction of TME the contribution of preoperative chemoradiation is relegate to local control with no or poor influence on survival, even if the absolute 5-year survival rate moved from 40% of the ’70 to 60-65% of the latest years1-3. From other side the growing evidence of an incidence of pCR approaching to 30%4, seems to identify a subset of patients with more favorable prognosis to neoadjuvant treatments5-6. Furthermore, the overall evidence that 30- 35% of rectal cancer patients treated with multimodality therapy still die from cancer namely by distant metastases in spite of the 4-8 % of absolute benefit of adjuvant 5Fu based adjuvant chemotherapy7, seems to vanish the efforts of the further optimization of the local treatments (surgery and radiotherapy) and of the ongoing modality of delivery the chemotherapeutic agents. We would like to address the main evidences from the literature and the main uncertainties that the surgeon could face to propose a combined treatment to his rectal cancer patient.
Functional outcome following restorative rectal cancer surgery  [PDF]
Zbar A.P.,Kennedy P.J.,Singh V.
Acta Chirurgica Iugoslavica , 2009, DOI: 10.2298/aci0902009z
Abstract: The trend towards preoperative adjuvant and neoadjuvant therapies in selected patients with rectal cancer has led to increases in sphincter preservation with a limited understanding of the factors governing unsatisfactory functional outcomes. Data would suggest the need for a more selective use of standard radiotherapeutic fields in low- to intermediate-risk cases where there appears to be limited survival or locoregional recurrence benefit and where there is under-reported toxicity. This article discusses the complex factors which impact on functional outcome following open rectal cancer surgery particularly when it is accompanied by adjuvant therapy.
Rectal cancer - principles of diagnosis and multidisciplinary management
Maria-Gabriela Ani?ei,V. Scripcariu
Jurnalul de Chirurgie , 2012,
Abstract: The management of rectal cancer requires an individualized, multidisciplinary approach, based on careful assessment of tumor location, stage and resectability. Pretreatment staging by MRI scan is now standard and should be repeated following preoperative chemoradiotherapy (CRT). For locally advanced rectal cancer, preoperative CRT increases the rate of tumor response and decrease the rate of local recurrence. Curative treatment of rectal cancer is based on surgical excision which combines the gold standard proctectomy, total mesorectal excision (TME) with autonomic nerve preservation and sphincter preservation, if the level of the tumor permits. The most important factor in rectal surgery is circumferential resection margins (CRM), negative CRM being associated with a better outcome, decreased risk of local recurrence and distant metastases and increased survival. The quality of oncological results is influenced by the degree of specialization of the surgeon and the center where the patient is operated.
Risk factors for adverse outcome in low rectal cancer  [cached]
Zhi-Hui Chen,Xin-Ming Song,Shi-Cai Chen,Ming-Zhe Li
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i1.64
Abstract: AIM: To demonstrate the oncologic outcomes of low rectal cancer and to clarify the risk factors for survival, focusing particularly on the type of surgery performed. METHODS: Data from patients with low rectal carcinomas who underwent surgery, either sphincter-preserving surgery (SPS) or abdominoperineal resection (APR), at The First Affiliated Hospital of Sun Yat-sen University in China from August 1994 to December 2005 were retrospectively analyzed. RESULTS: Of 331 patients with low rectal cancer, 159 (48.0%) were treated with SPS. A higher incidence of positive resection margins and a higher 5-year cumulative local recurrence rate (14.7% vs 6.8%, P = 0.041) were observed in patients after APR compared to SPS. The five-year overall survival (OS) was 54.6% after APR and 66.8% after SPS (P = 0.018), and the 5-year disease-free survival (DFS) was 52.9% after APR and 65.5% after SPS (P = 0.013). In multivariate analysis, poor OS and DFS were significantly related to positive resection margins, pT3-4, and pTNM III-IV but not to the type of surgery. CONCLUSION: Despite a higher rate of positive resection margins after APR, the type of surgery was not identified as an independent risk factor for survival.
Outcome of Laparoscopic Resection for Left Sided Colon and Rectal Cancer  [PDF]
Hamdy Abdelhady, Taha A. Esmail, Mohamed A. Hablus, Osama Hassan, Mahmoud Elsherif, Mohamed M. Elshheikh
Journal of Cancer Therapy (JCT) , 2017, DOI: 10.4236/jct.2017.81005
Abstract: Background: For many years, traditional surgery for left colon and rectal cancers had developed with variable degrees of morbidity. With the evolution of laparoscopy and by the aid of better visualization and magnification, laparoscopic colorectal surgery had appeared, but technically challenging as it involves almost all advanced laparoscopic techniques, with the benefits of minimal morbidity, less pain, earlier recovery, shorter hospital stay, without compromising oncological results. Aim: The aim of this work was to evaluate laparoscopic resection for left sided colon and rectal cancer as regard feasibility, safety and outcomes. Patients and Methods: This prospective study was conducted on 40 patients having left sided colon and rectal cancer, including 29 patients with rectal cancer and 11 patients with left sided colon cancer within the inclusion criteria are evaluated by clinical examination, radiological and colonoscopic study and biopsy and treated by laparoscopic resection and followed ranged from 6 months to 2 years with mean of 20 months. Results: Twenty seven patients (67.5%) underwent laparoscopic anterior resection, 11 patients (27.5%) underwent laparoscopic left hemicolectomy and only 2 patients (5%) underwent laparoscopic abdominoperineal resection, minimal morbidity, no cancer related mortality and no recurrence during the period of follow up either local or systemic. Conclusion: Laparoscopic resection for left sided colon and rectal cancer is technically feasible, oncologically safe and has more benefits on postoperative recovery.
Clinical Outcome of Laparoscopic Intersphincteric Resection Combined with Transanal Rectal Dissection for T3 Low Rectal Cancer in Patients with a Narrow Pelvis  [PDF]
Kimihiko Funahashi,Hiroyuki Shiokawa,Tatsuo Teramoto,Junichi Koike,Hironori Kaneko
International Journal of Surgical Oncology , 2011, DOI: 10.1155/2011/901574
Abstract: Purpose. The purpose of this study was to analyze the safety and feasibility of laparoscopic intersphincteric resection (ISR) combined with transanal rectal dissection (TARD) for T3 low rectal cancer in a narrow pelvis. Methods. We studied 20 patients with a narrow pelvis of median body mass index 25.3 (16.9–31.2). Median observation period was 23.6 months (range 12.2–56.7). Results. Partial, subtotal, and total ISR was performed in 15, 1, and 4 patients, respectively. Median duration of TARD was 83?min (range 43–135). There were no major complications perioperatively or postoperatively. Surgical margins were histologically free of tumor cells in all patients, and there was no local recurrence. Excluding urgency, frequency of bowel movements, and incontinence status improved gradually after stoma closure. Conclusion. Laparoscopic ISR combined with TARD is technically feasible for selective T3 low rectal cancer in patients with a narrow pelvis. 1. Introduction Intersphincteric resection (ISR) to preserve anal sphincter function for low rectal cancer extending into the anal canal was reported by Schiessel et al. in 1994 [1]. The feasibility of ISR has been demonstrated by surgeons since that time; it is now technically possible to use ISR to remove low rectal cancer with preservation of anal sphincter function with a satisfactory oncologic outcome [2, 3]. Recently, the clinical outcome of ISR as a laparoscopic approach (laparoscopic ISR) has been reported, but laparoscopic ISR for patients with bulky low rectal cancer remains challenging. Particularly for T3 tumors in patients with a narrow pelvis, it is important to achieve a low local recurrence. Total mesorectal excision (TME), negative circumferential margin (CFM), and tumor free surgical margin are prerequisites regardless of approach of ISR. Conversion to open operation in laparoscopic ISR may influence prognosis, as is the case in laparoscopic surgery for rectal cancer [4]. We have shown that transanal rectal dissection (TARD) performed prior to the abdominal phase of the operation is very useful for an adequate oncologic resection in laparoscopic ISR for T3 low rectal cancer in patients with a narrow pelvis [5]. The purpose of this report is to evaluate the safety and feasibility of TARD to achieve laparoscopic ISR for T3 low rectal cancers in patients with a narrow pelvis. 2. Patients Preoperative staging evaluation included digital rectal examination, barium enema, colonofiberscope with biopsy, computed tomography (CT), magnetic resonance imaging (MRI), and transanal ultrasound (TAUS). The
Rectal cancer treatment and outcome in the elderly: an audit based on the Swedish rectal cancer registry 1995–2004
B?rbel Jung, Lars P?hlman, Robert Johansson, Erik Nilsson
BMC Cancer , 2009, DOI: 10.1186/1471-2407-9-68
Abstract: We utilized data in the Swedish Rectal Cancer Registry (SRCR) from patients treated for rectal cancer in Sweden in 1995–2004.A total of 15,104 patients with rectal cancer were identified, 42.4% of whom were 75 years or older. Patients ≥75 years were less likely to have distant metastases than younger patients (14.8% vs. 17.8%, P < 0.001), and underwent abdominal tumor resection less frequently (68.5% vs. 84.4%, P < 0.001). Of 11,725 patients with abdominal tumor resection (anterior resection [AR], abdominoperineal excision [APE], and Hartmann's procedure [HA]), 37.4% were ≥75 years. Curative surgery was registered for 85.0% of patients ≥ 75 years and for 83.9% of patients < 75 years, P = 0.11. Choice of abdominal operation differed significantly between the two age groups for both curative and non-curative surgery, The frequency of APE was similar in both age groups (29.5% vs. 28.6%), but patients ≥75 years were more likely to have HA (16.9% vs. 4.9%) and less likely to have preoperative radiotherapy (34.3vs. 67.2%, P < 0.001). The relative survival rate at five years for all patients treated with curative intent was 73% (70–75%) for patients ≥75 years and 78% (77–79%) for patients < 75 years of age. Local recurrence rate was 9% (8–11%) for older and 8% (7–9%) for younger patients.Treatment of rectal cancer is influenced by patient's age. Future studies should include younger and older patients alike to reveal whether or not age-related differences are purposive. Local recurrence following surgery for low tumors and quality of life aspects deserve particular attention.Rectal cancer predominantly affects persons over the age of 50. The annual number of rectal cancer cases diagnosed in Sweden has increased over the last twenty years, mainly due to the increasing age of the Swedish population, a trend that is expected to continue [1,2]. Previous studies indicate that there is less inclination to perform surgery and adjuvant oncological treatment in elderly patients [3-
Valentin L. Ignatov,Nikola Y. Kolev,Anton Y. Tonev,Georgi H. Ivanov
Journal of IMAB : Annual Proceeding (Scientific Papers) , 2012,
Abstract: BACKGROUND: Laparoscopic surgery has been reported to be one of the approaches for total mesorectal excision (TME) in rectal cancer surgery. Intersphincteric resection (ISR) has been reported as a promising method for sphincter-preserving operation in selected patients with very low rectal cancer. METHODS: We try to underline the important surgical issues surrounding the management of patients with low rectal cancer indicated to laparoscopic intersphincteric resection (ISR). From January 2007 till now, 35 patients with very low rectal cancer underwent laparoscopic TME with ISR. We report and analyze the results from them RESULTS: Conversion to open surgery was necessary in one (3%) patient. The median operation time was 293 min and median estimated blood loss was 40 ml. The pelvic plexus was completely preserved in 32 patients. There was no mortality. Postoperative complications occurred in three (9%) patients. The median length of postoperative hospital stay was 11 days. Macroscopic complete mesorectal excision was achieved in all cases. Complete resection (R0) was achieved in 21 (91%) patients.CONCLUSIONS: Laparoscopic TME with ISR is technically feasible and a safe alternative to laparotomy with favorable short-term postoperative outcomes. The literature research made by us found that the laparoscopic approach can be underwent in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery.
The Quality Initiative in Rectal Cancer (QIRC) trial: study protocol of a cluster randomized controlled trial in surgery
Marko Simunovic, Charles Goldsmith, Lehana Thabane, Robin McLeod, Franco DeNardi, Timothy J Whelan, Mark N Levine
BMC Surgery , 2008, DOI: 10.1186/1471-2482-8-4
Abstract: Hospitals were randomized to the QIRC strategy (experimental group) versus normal practice environment (control group). Participating hospitals, and the respective surgeon group operating in them, are from Ontario, Canada and have an annual procedure volume for major rectal cancer resections of 15 or greater. Patients were eligible if they underwent major rectal surgery for a diagnosis of primary rectal cancer. The surgeon-directed QIRC interventions included a workshop, use of opinion leaders, operative demonstrations, a post-operative questionnaire, and, audit and feedback. For an operative demonstration participating surgeons invited a study team surgeon to assist them with a case of rectal cancer surgery. The intent was to demonstrate total mesorectal excision techniques. Control arm surgeons received no intervention. Sample size calculations were two-sided, considered the clustering of data at the hospital level, and were driven by requirements for the outcome local recurrence. To detect an improvement in local recurrence from 20% to 8% with confidence we required 16 hospitals and 672 patients – 8 hospitals and 336 patients in each arm. Outcomes data are collected via chart review for at least 30 months after surgery. Analyses will use an intention-to-treat principle and will consider the clustering of data. Data collection will be complete by the end of 2007.Lower rates of permanent colostomy and local tumour recurrence in the intervention arm would suggest the QIRC strategy is efficacious. The strategy may act as a template for efforts to improve surgical quality in other areas and will contribute to knowledge on influencing surgeon practice.Current Controlled Trials ISRCTN78363167Surgical resection of rectal cancer is the cornerstone of curative therapy. Typically during rectal cancer surgery the tumour and a contiguous segment of normal bowel are removed and the bowel tract reestablished. For surgically treated patients two unfortunate outcomes are permanen
Rectal cancer: Pattern and outcome of management in University of Ilorin teaching hospital, Ilorin, Nigeria
GA Rahman
Annals of African Medicine , 2010,
Abstract: Background: Cancer of the colon and rectum was considered to be rare in Africa three to four decades ago. This is no longer true though it is not as common as in Western Europe and North America. The aim of this study is to determine the incidence of rectal cancer, its pattern of presentation, diagnosis, treatment and outcome of treatment at the University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria. Methods: This is a prospective study of all the patients with rectal cancer seen at the UITH from January 1998 to December 2002. Clinical and radiologic findings as well as findings at surgery were recorded and evaluated. They were all histologically confirmed. The data were analyzed using SPSS 10.0. Results: Thirty-six patients with rectal cancer were seen during the period. The male to female ratio was 1:1. Fourteen (38.9%) of the patients were younger than 40 years. Only three (8.3%) patients presented as emergency. Eighteen patients had resectable lesions at presentation. Ten had abdomino-perineal (A-P) resection and eight had anterior resection. Operative mortality was 5.9%. Ten (60%) of the patients who had A-P resection were alive at 5 years and 62.5% of those who had anterior resection were alive at 5 years. None of the patients who had unresectable tumors was alive at 5 years. Conclusion: Rectal cancer is not rare in Africans. Surgical therapy still remains as the main treatment. When patients present early, outcome is satisfactory. Since most cases in this environment are accessible to digital rectal examination (DRE), the need for this procedure in patients with lower gastrointestinal symptoms cannot be overemphasized.
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