Sphincter preservation operation and comprehensive treatment for ultra-low rectal cancer / 中华消化外科杂志

In the past 20 years, the multidisciplinary treatment model based on evidence-based medicine has significantly increased the rate of sphincter-preservation operation for rectal cancer. How to preserve rectum and anal function, avoid permanent colostomy, and improve post-operative quality of life of patients while ensuring radical resection of tumor, remains to be a key and hot topic in surgical treatment of rectal cancer. Based on literatures and clinical experiences, the authors summarize issues of sphincter preservation operation and comprehensive treatment, including intersphincteric resection, conformal sphincter preservation operation, total neoadjuvant therapy and radioimmunotherapy, for ultra-low rectal cancer, in order to provide reference for the colleagues.

Reassessment of intersphincteric resection in the sphincter-preserving operation for ultra-low rectal cancer / 中华胃肠外科杂志

Intersphincteric resection (ISR), as an ultra-low sphincter-preserving operation, is widely used in clinical practice at present. ISR can allow some patients with very low rectal cancer to avoid the pain of anal resection while ensuring oncological efficacy. However, the procedure of ISR requires wider intersphincteric dissection which may cause nerve damage, and the removal of partial or total internal anal sphincter as an "inherent defect" of ISR can result in poor anal function postoperatively. Based on the in-depth understanding of regional anatomy and physiological function, the author proposed a new functional sphincter preservation operation for very low rectal cancer-conformal sphincter preservation operation (CSPO) which has achieved good outcome in clinical practice. This article will revisit the brief history of rectal cancer surgery and discuss the main mechanisms underlining the poor anal function after ISR. Based on the anatomical study of the pelvic floor and anal canal, CSPO can improve the postoperative anal function of very low rectal cancer patients by reducing the damage of the autonomic nerves, receptor corpuscles and muscle fibers in the intersphincteric space, retaining more dentate line and internal sphincter with the design of resection line of tumor lower border under direct vision, and elevating the anastomosis height. At the same time, the future treatment prospect of low rectal cancer is envisioned.

Effectiveness of biofeedback training among rectal cancer patients: a randomized controlled trial / 中国实用护理杂志

Objective@#To evaluate the effect of biofeedback training on bowl function among rectal cancer patients with chemoradiotherapy and temporary enterostomy.@*Methods@#Using randomized controlled trial design, 109 rectal cancer patients were randomly divided into three groups, the first blank control group, the second group pelvic floor muscle exercise group, the third group biofeedback group. High resolution anorectal manometry was used for 6 longitudinal traces in 16 months. Data of bowel function were collected by Memorial Sloan Kettering Cancer Center (MSKCC) Bowel Function Instrument.@*Results@#The main effect of the change of five indicators, anal resting pressure, rectal resting pressure, maximum squeeze pressure, maximum squeeze time and high pressure zone, was time. The other four indicators, rectal volume at first senory, rectal volume at sense of convenience, maximal tolerable rectal volume and rectal compliance, among patients of biofeedback group were (32.71±5.00) ml, (74.26±8.30) ml, (188.40±12.68) ml, (5.69±1.18) ml/kPa and (68.09±6.38). The rectal volume at first senory, rectal volume at sense of convenience, maximal tolerable rectal volume and rectal compliance, among patients of biofeedback group were significant higher than blank control group and pelvic floor muscle exercise group (F=3.589-26.826, P<0.05).@*Conclusion@#The biofeedback could significantly improve the sensory indicators of patients with middle and low rectal cancer. High-resolution anorectal manometry could effectively evaluate the effect of biofeedback training in patients with middle and low rectal cancer.

Analysis on prognosis and influencing factors of postoperative low anterior resection syndrome for rectal cancer patients undergoing laparoscopic anus-preserving radical resection / 中华胃肠外科杂志

Objective@#To investigate the prognosis and influencing factors of postoperative low anterior resection syndrome (LARS) for rectal cancer patients undergoing laparoscopic sphincter-preserving radical resection.@*Methods@#A retrospective case-control study was used in this study. Clinical data of 268 rectal cancer patients undergoing laparoscopic sphincter-preserving radical resection at Department of Gastrointestinal Surgery of The First Affiliated Hospital of Bengbu Medical College from January 2016 to January 2018 were retrospectively collected. Inclusion criteria: (1) operation procedure was total mesorectal excision (TME) and sphincter-preserving radical resection; (2) rectal cancer was confirmed by postoperative pathology; (3) age of patient was ≥ 18 years old. Exclusion criteria: (1) patient who had history of pelvic surgery and pelvic fractures, which would affect the anorectal function; (2) patient who had history of preoperative chronic constipation and irritable bowel syndrome, which would affect defecation; (3) patient who developed postoperative complications, such as anastomotic leakage, which would affect defecation function; (4) patient who received long-term use of drugs, which would affect the function of gastrointestinal tract or anus; (5) patient suffered from mental illness, who was unable to communicate properly; (6) patient who was lack of clinical data or had incomplete clinical data. Patients were followed up at 3, 6 and 12 months postoperatively, and LARS was diagnosed and graded according to the LARS score scale. The LARS score ranged from 0 to 42 points, and 0 to 20 was difined as no LARS, 21 to 29 was mild LARS, and 30 to 42 was severe LARS. LARS score >20 points at any time point was defined as postoperative LARS. Severe LARS transferring into mild LARS and mild LARS transferring into no LARS was defined as symptom improvement. Incidence and outcomes of LARS were evaluated. The factors associated with LARS outcomes were analyzed using χ2 test and logistic regression model.@*Results@#A total of 268 patients were enrolled. The incidence of LARS was 42.9% (115/268), 32.5% (87/268) and 20.1% (54/268) at 3, 6, and 12 months postoperatively respectively, and no new case of LARS was found after 3 months postoperatively. The incidence of mild LARS was 25.7% (69/268), 17.2% (46/268) and 8.6% (23/268) at 3, 6, and 12 months postoperatively respectively, and mild LARS incidence at 6 months was significantly lower than that at 3 months (χ2=5.857, P=0.016), and was significantly higher than that at 12 months (χ2=8.799, P=0.003). The incidence of severe LARS was 17.2% (46/268), 15.3% (41/268) and 11.6% (31/268) at 3, 6, and 12 months postoperatively respectively, without significant difference among 3 time points (all P>0.05). The improvement rate within one year after surgery in patients with mild LARS diagnosed at 3 months was significantly higher than that in patients with severe LARS (88.4% vs. 32.6%, χ2=38.340, P<0.001). Univariate analysis showed that female, distance from anastomosis to anal verge < 5 cm and tumor diameter ≥ 5 cm were associated with unsatisfied LARS outcomes (all P<0.05). Logistic regression analysis showed that distance from anastomosis to anal verge <5 cm was an independent risk factor for LARS outcome (OR=3.589, 95% CI: 1.163 to 2.198, P<0.001).@*Conclusions@#The incidence of LARS after laparoscopic sphincter-preserving radical resection decreases with time. The improvement rate within postoperative 1-year of severe LARS is lower than that of mild LARS. Low anastomotic position may lead to impaired improvement of LARS.

Progress in the application of preventive stoma in anal sphincter preservation for low rectal cancer / 国际外科学杂志

With the development of modem medical technology,the change of operation concept and the innovation of operation mode,more and more patients are able to cure low rectal cancer while achieving the goal of retaining the anus.Anastomotic fistula is the most serious complication after anal sphincter preservation for low rectal cancer,and it is also the main cause of death,and the factors are complicated.In order to prevent anastomotic leakage and reduce the harm caused by it,most scholars at home and abroad recommend the use of preventive stoma.This article reviews the application of prophylactic stoma in anal sphincter preservation for low rectal cancer,and provides valuable information for the application of preventive stoma in anal sphincter preservation for low rectal cancer.

Técnicas quirúrgicas para la preservación de esfínter en cáncer de recto bajo: revisión histórica y estado actual / Surgical techiniques for sphincter preservation y low rectal cancer: historical review and current status

Resumen Tras múltiples intentos para lograr resultados apropiados en una resección quirúrgica por cáncer de recto, Sir William Ernest Miles desarrolla la técnica que posteriormente llevará su nombre, y que se conoce actualmente, sin muchas modificaciones, como resección abdominoperineal. Esta técnica, considerada el gold standard para tumores de recto por muchos años, fue progresivamente reemplazada por las técnicas de preservación de esfínter. La resección anterior baja permitió preservar el esfínter a paciente con tumores de recto a más de 5 cm del margen anal. El desarrollo técnico (suturas grapadas), mejor entendimiento de principios oncológicos (resección total del mesorrecto) y la introducción de la neoadyuvancia con quimioradioterapia, permitió bajar el margen de sección distal considerado adecuado y realizar anastomosis colorrectales ultrabajas y coloanales. La resección ultrabaja interesfintérica reseca el esfínter anal interno (en forma total, subtotal o parcial) logrando evitar la colostomía permanente en un grupo de pacientes. Esta técnica, ha sido ampliamente estudiada con resultados oncológicos publicados que resultan mejores o similares que los de la resección abdominoperineal. Actualmente la evaluación de respuesta a neoadyuvancia, ha llevado a algunos grupos de trabajo a plantear la preservación del órgano; ya sea mediante el seguimiento estricto tras respuesta clínica completa, como técnicas de resección local en respuesta incompleta.

After multiple attempts to achieve appropriate results in the surgical resection for rectal cancer, Sir William Ernest Miles develops the technique that would carry his name, and is, without modifications, currently referred as abdominoperineal resection. This technique, considered gold standard for rectal tumors for many years, has been gradually replaced by sphincter preserving surgery. Low anterior resection allowed sphincter-preservation in patients with low rectal tumors within 5 cm from the anal verge. Technical developments (double stapling technique), better understanding of oncological principles (total mesorectal excision) and the introduction of neoadyuvant treatment with chemoradiotherapy, allowed further lowering of the adequate distal resection margin and to carry out ultralow colorectal and coloanal anastomoses. Ultralow intersphincteric resection removes the internal anal sphincter (partial, subtotal or total resection) avoiding permanent colostomy in a subset of patients. This technique has been broadly studied with published oncological outcomes that are better or similar to those of abdominoperineal resection. Currently, evaluation of response after neoadyuvant therapy has led some working groups to propose organ preservation; either by strict follow up for complete clinical response, or by local excision techniques for incomplete clinical response.

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

PURPOSE: Tumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE. METHODS: Data on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle. RESULTS: A secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4. CONCLUSION: HLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

Functional outcome and quality of life following treatment for rectal cancer / Resultados funcionais e qualidade de vida após tratamento do câncer retal

Introduction: Over the last decades, treatment for rectal cancer has substantially improved with development of new surgical options and treatment modalities. With the improvement of survival, functional outcome and quality of life are getting more attention. Study objective: To provide an overview of current modalities in rectal cancer treatment, with particular emphasis on functional outcomes and quality of life. Results: Functional outcomes after rectal cancer treatment are influenced by patient and tumor characteristics, surgical technique, the use of preoperative radiotherapy and the method and level of anastomosis. Sphincter preserving surgery for low rectal cancer often results in poor functional outcomes that impair quality of life, referred to as low anterior resection syndrome. Abdominoperineal resection imposes the need for a permanent stoma but avoids the risk of this syndrome. Contrary to general belief, long-term quality of life in patients with a permanent stoma is similar to those after sphincter preserving surgery for low rectal cancer. Conclusion: All patients should be informed about the risks of treatment modalities. Decision on rectal cancer treatment should be individualized since not all patients may benefit from a sphincter preserving surgery "at any price". Non-resection treatment should be the future focus to avoid the need of a permanent stoma and bowel dysfunction.

Introdução: Ao longo das últimas décadas, o tratamento do câncer retal melhorou substancialmente com o desenvolvimento de novas opções terapêuticas. Com a melhoria da sobrevida, os resultados funcionais e a qualidade de vida são cada vez mais tidos em consideração. Objetivos do estudo: Rever as modalidades atuais de tratamento do câncer retal, com enfase nos resultados funcionais e qualidade de vida. Resultados: Os resultados funcionais após tratamento para o câncer retal é influenciado pelas características do doente, do tumor, da técnica cirúrgica, do uso de radioterapia pré-cirúrgica e do método e nível da anastomose. A cirurgia poupadora de esfíncter do câncer retal baixo resulta frequentemente em maus resultados funcionais que prejudicam a qualidade de vida, denominados síndrome da ressecção anterior baixa. A amputação abdominoperitoneal impõe a necessidade de uma colostomia definitiva mas evita os riscos de resultados funcionais deficitários. Contrariamente à crença geral, a qualidade de vida a longo-prazo em doentes com colostomia definitiva é semelhante à qualidade de vida após cirurgia poupadora de esfíncter do câncer retal baixo. Conclusão: Todos os doentes devem ser informados sobre o risco das opções terapêuticas. A decisão do tratamento do câncer retal deve ser individualizada uma vez que nem todos os doentes beneficiarão de uma cirurgia poupadora de esfíncter "a qualquer preço". A possibilidade de tratamento sem ressecção devem ser o foco futuro para evitar a necessidade de uma colostomia definitiva e disfunção gastrointestinal.

Meta analysis of laparoscopic versus open total mesorectal excision with sphincter-preservation for treating low rectal cancer / 重庆医学

Objective To evaluate the safety and efficacy of laparoscopitotal mesorectal excision (TME) with sphincter-preservation in the treatmenof low rectal cancerby using metanalysi.MethodThe electronidatabase(PubMed ,Medline ,Ov-id ,Cochrane Library ,Controlled TrialRegistry ,SinoMedCBM ,Wanfang Dat,CNKI ,VIP ,eal) were retrieved .The related litera-tureon the randomized controlled trail(RCTs) and the non-randomized controlled trails(non-RCTs) comparing laparoscopiver-sulaparotomy TME with sphincter-preservation fotreating low rectal cancepublished from January 2001 to Octobe2012 were collected .The RevMan5 .2 software waused to conducthe metanalysi.ResultTwelve studieincluding 1 508 patientwere included ,in which the laparoscopigroup had 781 caseand the laparotomy group had 727 case.The metanalysiresultshowed thacompared with the laparotomy group ,the laparoscopiTME(LTME) group with sphincter-preservation had significantly lesestimated blood loss[mean difference(MD)= -67 .13 ,95% confidence interval(CI) (-78 .74 ,-55 .51) ,P＜0 .01] ,longedistal resection margins[MD=0 .15 ,95% CI(0 .01 ,0 .29) ,P= 0 .04] ,earlieintestinal functional recovery [MD= -1 .16 ,95% CI (-1 .32 ,-1 .01) ,P＜0 .01] ,shortehospital stay [MD= -3 .99 ,95% CI (-5 .36 ,-2 .63) ,P＜0 .01) ,lestotal morbidity [oddratio(OR)=0 .40 ,95% CI (0 .25 ,0 .63) ,P＜0 .01] ,anastomotileakage[OR=0 .60 ,95% CI (0 .37 ,0 .96) ,P=0 .03] ,urinary re-tention[OR=0 .40 ,95% CI(0 .18 ,0 .87) ,P=0 .02] and incision infection[OR=0 .26 ,95% CI(0 .11 ,0 .61) ,P=0 .002] .The statis-tically significandifferencewere nofound between the two groupin the numbeof lymph node dissection,length of resected specimen ,postoperative obstruction and the 2-yeaoverall survival rate(P＞0 .05) .Conclusion LTME with sphincter-preservation fotreating low rectal cancehathe advantageof lessurgical traum,rapid postoperative recovery and few complication.Never-theles,iineeded to conducfurtheresearch fovalidating whetheLTME with sphincter-preservation having the superiority in the aspectof postoperative anal function recovery and long-term outcome .

Total mesorectal excision and sphincter preservation: the early steps of rectal cancer surgery / Excisão total do mesorreto e esfíncter: os primeiros passos de uma cirurgia de câncer retal

The treatment of rectal cancer has evolved significantly over the last 100 years. Standardization of total mesorectal excision and the development of techniques for sphincter preservation have resulted in significant improvements in the management of this disease. Still, local disease control and functional outcomes of sphincter preserving procedures remain a relevant issue. In this historical paper, the oncological and functional outcomes of patients with rectal cancer treated between 1960 and 1971 by a pioneer woman surgeon using a sphincter preserving approach and a technique resembling total mesorectal excision performed at that time are reported. The results reflect one of the earliest steps of partial intersphincteric resection and total mesorectal excision with good oncological outcomes (2% local recurrence) and acceptable functional outcomes in a highly selected group of patients. (AU)

O tratamento do câncer de reto tem evoluído significativamente ao longo dos últimos 100 anos. A padronização da excisão total do mesorreto e o desenvolvimento de técnicas com preservação do esfíncter resultaram em melhorias significativas no tratamento da doença. Ainda assim, o controle local da doença e os resultados funcionais dos procedimentos de preservação do esfíncter continuam a ser uma questão relevante. Nesse documento histórico, são relatados os resultados oncológicos e funcionais de pacientes com câncer retal, tratados entre 1960 e 1971, utilizando-se uma abordagem com preservação do esfíncter e uma técnica parecida com a excisão total do mesorreto realizada por uma cirurgiã pioneira naquela época. Os resultados refletem um dos primeiros passos de ressecção parcial interesfinctérica e a excisão total do mesorreto com bons resultados oncológicos (2% de recidiva local), e os resultados funcionais aceitáveis em um grupo altamente selecionado de pacientes. (AU)

The efficacy of neoadjuvant concurrent chemoradiotherapy or radiotherapy alone in patients with locally advanced rectal cancer / 中华放射肿瘤学杂志

Objective To observe the efficacy and safety of preoperative concurrent chemoradiotherapy or radiotherapy alone in patients with T3,T4 or lymph node-positive rectal cancer.Methods 141 rectal cancer patients with locally advanced or node-positive based on imaging from 2000 to 2009 were retrospective analyzed.Ninety-seven patients received preoperative concurrent chemoradiotherapy and 44 received preoperative radiotherapy alone.Two-dimensional or three-dimensional radiation technique and four types of chemotherapy regimens were used.Results The following-up rate was 91.5％.106 patients were followed up for at least 3 years and 68 patients for at least 5 years.The 3-and 5-year overall survival rates were 85.8％ and 65.7％,respectively.The 3-and 5-year local recurrence rates were 9.2％ and 14.1％,respectively.The 3-and 5-year metastasis rates were 33.8％ and 45.8％,respectively.The downstaging rate was up to 59.0％ (82/139) and the rate of sphincter preservation was 65.5％ (91/139).The median disease-free survival in patients treated with preoperative concurrent chemoradiotherapy was superior to radiotherapy alone (51 months vs 31 months,x2 =12.88,P =0.000).The time to metastasis in patients with downstaging was significantly delayed than that in patients without downstaging (60 months vs 29 months,x2 =14.65,P =0.000).Most acute toxicity was grade 1 and grade 2.The incidence of delayed wound healing and anastomotic leakage was very low.Conclusions Preoperative concurrent chemoradiotherapy or radiotherapy alone has excellent tumor downstaging effect and helps in sphincter preservation,with tolerable side effects.

Rectal Cancer: Function-preserving Surgery

The main goals in the surgical treatment of rectal cancer are to remove the cancer completely and to preserve the anorectal function. Rectal cancer is one of the leading health issues in Korea because of its increasing incidence with changing lifestyles and diets. The optimal treatment of rectal cancer is based on a multimodality approach. Among the modalities, proper surgery is the key for a curative treatment. In the early 20th century, local recurrence was reported to be as high as 30~40%. However, after the introduction of total mesorectal excision (TME), local recurrence decreased dramatically (to less than 10%). TME includes on sharp pelvic mesorectal dissection and complete clearing of the rectal cancer and the mesorectum along the rectal proper fascia. TME is now considered as a standard procedure for surgical treatment of rectal cancer. These days, sphincter-saving surgical techniques, such as transanal excision, ultralow anterior resection with coloanal anastomosis, and intersphincteric resection, have become popular for the treatment of low rectal cancer. Many researchers reported that oncologic outcomes were not compromised by the increased sphincter preservation rate. In clinical settings, the quality of life should be considered important because of the improved oncologic results in recent years. Surgeon should be aware of changes in the anorectal function after surgery. Reservoir and fecal continence, as well as sexual and voiding functions, should be closely evaluated during follow-up period. Impaired anorectal function may have multiple contributing factors: for example, a reduced reservoir volume, an unnoticed complex injury of the anal sphincter, or a traction injury (anal dilation). In terms of poor sexual and voiding functions, identification of the autonomic nerve plexus in the operative field is not enough for preserving the sexual and voiding functions. During pelvic dissection, traction injury caused by blunt dissection and electrothermal or vasa nervosum injury during sharp perimesorectal dissection should be avoided for better functional results. Preoperative or postoperative radiation may also be a reason for sexual and voiding dysfunction. If the ultimate goal of rectal cancer surgery is to be achieved, precise surgical technique and proper patient selection are mandatory. This issue contains recent advances in sphincter-saving surgery and nerve preservation for rectal cancer, which will be a useful reference for colorectal surgeons.

Results of Preoperative Concurrent Chemoradiotherapy for Locally Advanced Rectal Cancer / 대한방사선종양학회지

PURPOSE: We performed a retrospective non-randomized clinical study of locally advanced rectal cancer, to evaluate the anal sphincter preservation rates, down staging rates and survival rates of preoperative chemoradiotherapy. MATERIALS AND METHODS: From January 2002 to December 2005, patients with pathologically confirmed rectal cancer with clinical stage T2 or higher, or patients with lymph node metastasis were enrolled in this study. A preoperative staging work-up was conducted in 36 patients. All patients were treated with preoperative chemoradiotherapy, and curative resection was performed for 26 patients at Hallym University Sacred Heart Hospital. Radiotherapy treatment planning was conducted with the use of planning CT for all patients. A total dose of 45.0~52.2 Gy conventionally fractionated three-dimensional radiotherapy was delivered to the whole pelvis. Chemotherapy was given at the first and fifth week of radiation therapy with continuous infusion i.v. 5-FU (Fluorouracil) and LV (Leucovorine). Surgical resection was performed 2 to 4 weeks after the completion of the chemoradiotherapy regimen. RESULTS: The complete resection rate with negative resection margin was 100% (26/26). However, a pathologically complete response was not seen after curative resection. Surgery was done by LAR (low anterior resection) in 23 patients and APR (abdomino-perineal resection) in 3 patients. The sphincter preservation rate was 88.5% (23/26), down staging of the tumor occurred in 12 patients (46.2%) and down-sizing of the tumor occurred in 19 patients (73%). Local recurrence after surgical resection developed in 1 patient, and distant metastasis developed in 3 patients. The local recurrence free survival rate, distant metastasis free survival rate, and progression free survival rate were 96.7%, 87% and 83.1%, respectively. Treatment related toxicity was minimal except for one grade 3, one grade 4 anemia, one grade 3 leukopenia, and one grade 3 ileus. CONCLUSION: Preoperative concurrent chmoradiotherapy for locally advanced rectal cancer seems to have some potential benefits: high sphincter preservation and down staging. Treatment related toxicity was minimal and a high compliance with treatment was seen in this study. Further long-term follow-up with a larger group of patients is required.

Long-term Result for Rectal Cancer in Cases of a Curative Resection after Preoperative Chemoradiotherapy

PURPOSE: Preoperative chemoradiation is the recommended standard therapy for locally advanced rectal cancer and is associated with sphincter preservation and improved survival. Our study was performed to determine the surgical outcomes and the prognostic factors for rectal cancer with preoperative chemoradiotherapy (PCRT) followed by a relative curative resection. METHODS: We retrospectively reviewed the cases of 251 advanced rectal cancer patients who underwent a PCRT, between Jan 1995 and Dec 2002. All patients a received 25 days RTX (total dose: 4,500~5,040 cGy) and intravenous 5-FU (425 mg/m2/ day) plus leucovorin (20 mg/day) for 24 hrs. Surgery was performed about 4~6 weeks after completion of RTX. The median follow up was 79 months (range 1-142). RESULTS: All patients were comfortable with PCRT. Postoperative mortality was 1.1%. After PCRT, 92.2% of the patients and, especially, 82.2% of the low rectal cancer patients had sphincter preserving surgery. Complete remission of the tumor was stenin 15.1% of the cases, but was not significantly associated with recurrence. The overall recurrence and the local recurrence rates were 15.1% and 4.4%, respectively. Cell differentiation, circumferential margin, and lymphovascular invasion were independent risk factors for local recurrence in the multivariate analysis. Prognostic factors for overall and disease-free survival were cell differentiation, circumferential margin, lymphovascular invasion, and lymph node metastasis in the multivariate analysis. The 5-year disease-free survival rates for stages I, II, and III, and for no-residual tumor were 96.1%, 83.4%, 69.0%, and 89.1%, respectively (P<0.05). CONCLUSIONS: Advanced rectal cancer treated using preoperative chemoradiation resulted in excellent sphincter preservation. Our long-term follow-up results showed good local control and improved survival for rectal cancer.

The Treatment Results of Preoperative Concurrent Chemoradiation in Locally Advanced Rectal Cancer / 대한암학회지

PURPOSE: To assess the tumor response, sphincter preservation, acute toxicity and survival with preoperative concurrent chemoradiation in locally advanced rectal cancer. MATERIALS AND METHODS: Fifty-four patients were treated with preoperative chemoradiaton for tumor downstaging and sphincter preservation. Radiation was delivered to whole pelvis to 45 Gy followed by a boost 5.4 Gy to primary tumor site. Chemotherapy consists of concurrent 2 cycles of 5-fluorouracil (500 mg/m2/day) and leucovorin (20 mg/m2/day). Surgery was performed approximately 6 weeks after treatment. RESULTS: Median follow-up period and rate were 48 months and 98%, respectively. The downstaging including primary tumor and lymph node occurred in 64%. Three of 53 patients (6%) had pathologic complete response. The resectability of tumor was 98%. A sphincter preservation was possible in 61%. Three patients developed grade 4 hematologic toxicity. Grade 3 skin erythema and diarrhea were 24% and 18%, respectively. The 5-year survival and local disease-free survival were 62% and 89%, respectively. Local failure and distant metastasis rate were 9% and 35%, respectively. CONCLUSION: Preoperative chemoradiation affords considerable downstaging with acceptable acute toxicity and postoperative morbidity. Also sphincter preservation is feasible by improved downstaging of tumor. This treatment could be improved local control of tumor, and may have a potential for long-term survival.

Pull-through Welch procedure for the lower rectal carcinoma: a report of 28 cases / 中国普通外科杂志

Objective To find a novel operative modality with sphincter preservation in the treatment of middle and low rectal carcinoma. Methods Pull through lower resection was performed on 28 rectal cancer patients. The distance between the anal verge and the lower margin of the tumor was 6～8cm(20 patients) or 8～10cm(8 patients), including 8 patients in Dukes A stage, 16 Dukes B and 4 Dukes C. The resected line from tumor distal margin was 2cm, 3cm, and 4cm, respectively. Results There was no operative death, anastomotic fistula or anastomotic stenosis in these cases. Mean follow up period was 30 months. Local recurrence was found in two cases (7.1%) 18 months after the operation, and 26 cases were cancer free till the end of the follow up. Defecation was satisfactorily controlled 8～12 weeks after the operation. Conclusions Pull through Welch procedure could meet the criterion of the radical resection of rectal carcinoma,and keep the internal and external sphincter muscles intact in the superior lower anterior resection. The normal defecationcan can maintain after the operation due to the preservation of internal and external sphincter muscles.