Oncologic Outcomes and Risk Factors for Recurrence after Tumor-specific Mesorectal Excision of Rectal Cancer: 782 Cases

PURPOSE: The aim of this study was to analyze the oncologic outcomes and the risk factors for recurrence after a tumor-specific mesorectal excision (TSME) of resectable rectal cancer in a single institution. METHODS: A total of 782 patients who underwent a TSME for resectable rectal cancer between February 1995 and December 2005 were enrolled retrospectively. Oncologic outcomes included 5-year cancer-specific survival and its affecting factors, as well as risk factors for local and systemic recurrence. RESULTS: The 5-year cancer-specific survival rate was 77.53% with a mean follow-up period of 61 +/- 31 months. The overall local and systemic recurrence rates were 9.2% and 21.1%, respectively. The risk factors for local recurrence were pN stage (P = 0.015), positive distal resection margin, and positive circumferential resection margin (P < 0.001). The risk factors for systemic recurrence were pN stage (P < 0.001) and preoperative carcinoembryonic antigen level (P = 0.005). The prognostic factors for cancer-specific survival were pT stage (P < 0.001), pN stage (P < 0.001), positive distal resection margin (P = 0.005), and positive circumferential resection margin (P = 0.016). CONCLUSION: The oncologic outcomes in our institution after a TSME for patients with resectable rectal cancer were similar to those reported in other recent studies, and we established the risk factors that could be crucial for the planning of treatment and follow-up.

Loop Colostomy with Not Everted Fashion for Rectal Cancer

PURPOSE: An anastomotic leak after resection of rectal cancer is a omnious complication. The diverting stoma is performed to avoid this serious complication. However, a diverting stoma and a stoma reversal are associated with significant morbidity and a small mortality. As stoma-related complications are associated with a delay of adjuvant therapy for advanced rectal cancer, minimal stoma-related morbidity is mandatory for rectal cancer patients. A safe and simple dissection of the stoma is known to be associated with less morbidity at stoma closure. Since in a loop colostomy of a not everted fashion, it is easy to construct and dissect the peristomal site at colostomy reversal, this study evaluated the usefulness of a protective loop colostomy of a not everted fashion in rectal cancer. METHODS: We reviewed the clinical records of 71 cases of loop colostomy closure for rectal cancer between January 1996 and December 2004. The clinical data, including indications for the stoma, the clinicopathologic features of the patients and their general conditions, the data for patients receiving adjuvant therapy, stoma-related morbidity, stoma-closure-related morbidity, and perioperative data were examined. RESULTS: Indications for stoma creation are the discretion of the surgeon (n=22), poor bowel preparation (n=21), unstable anastomosis (n=16), bowel obstruction (n=6), and anastomotic leakage (n=6). The stoma-related morbidity rate for a non-eversion colostomy was 5.6%. Morbidity events were peristomal erythema (n=2), prolapse (n=1), and parastomal hernia (n=1) requiring surgery. The stoma-closure-related morbidity rates was 9.9%. In the 45 patients undergoing adjuvant therapy, colostomy closure was performed during adjuvant therapy in 39 patients. Major complications, such as anastomotic leakage or abscess following reversal of the non-eversion colostomy, occurred in 1 of the 71 patients (1.4%). The average operating time and the blood loss for clostomy closure were 89.5 minutes and 202.3 ml, respectively. A simple closure of the loop colostomy was performed in 51 patients (71.8%). CONCLUSIONS: Based on our results, a non-eversion colostomy may be considered due to the ease of construction and reversal if a temporary diverting stoma for rectal cancer is indicated.

Clinical Significance of Lateral Resection Margin Involvement for Colon Cancer

PURPOSE: The clinical significance of the lateral resection margin for rectal cancer has been widely investigated. The ascending and the descending colon do not have a peritoneal covering posteriorly. Therefore, colon cancers located on their posterior side can penetrate the entire bowel wall, which is similar to mesorectal invasion in rectal cancer. However, the prognostic significance of the retroperitoneal resection margin involvement is unknown. The aim of this study is to evaluate the prognostic significance of the lateral resection margin in ascending and descending colon cancer. METHODS: A retrospective study was performed and involved 92 patients who had undergone a curative resection for right or left colon cancer with TNM stage II and III. The patients were assigned to either a lateral margin negative group (LMNG, n=73) or a lateral margin positive group (LMPG, n=19) according to the presence of a tumor or a metastatic lymph node within 1 mm of the lateral resection margin. The oncological outcomes of the LMPG were compared with those of the LMNG. RESULTS: The LMPG was younger and had higher incidences of tumors positive vascular or neural invasion and advanced T and N stages. The overall recurrence rate of the LMPG was higher than that of the LMNG (36.8% versus 16.4%) and the cumulative survival rate of the LMPG was significantly lower than that of the LMNG (35.0% versus 76.2%). High preoperative CEA, lymphatic invasion, lateral margin involvement of the tumor, N2 in nodal status were significant factors in the univariate analysis for evaluation of the prognosis, but lateral margin involvement was not a significant factor in the multivariate analysis. In the lymph-node-positive group and the CEA non-elevation group, lateral margin involvement of the tumor was revealed as a prognostic factor. CONCLUSIONS: Lateral margin involvement of ascending and descending colon cancer affects tumor recurrence and overall survival, but it is not a significant prognostic factor.