Quality indicators of transanal total mesorectal excision (TaTME) for rectal cancer

Introduction: Transanal total mesorectal excision (TaTME) has revolutionized the surgical techniques for lower-third rectal cancer. The aim of the present study was to analyze the outcomes of quality indicators of TaTME for rectal cancer compared with laparoscopic TME (LaTME). Methods: A cohort prospective study with 50 (14 female and 36male) patients, with a mean age of 67 (range: 55.75 to 75.25) years, who underwent surgery for rectal cancer. In total, 20 patients underwent TaTME, and 30, LaTME. Every TaTME procedure was performed by experienced colorectal surgeons. The sample was divided into two groups (TaTME and LaTME), and the quality indicators of the surgery for rectal cancer were analyzed. Results: There were no statistically significant differences regarding the patients and the main characteristics of the tumor (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI], tumoral stage, neoadjuvant therapy, and distance from the tumor to the external anal margin) between the two groups. The rates of: postoperativemorbidity (TaTME: 35%; LaTME: 30%; p=0.763);mortality (0%); anastomotic leak (TaTME: 10%; LaTME: 13%; p=0.722); wound infection (TaTME: 0%; LaTME: 3.3%; p=0.409); reoperation (TaTME: 5%; LaTME: 6.6%; p=0.808); and readmission (TaTME: 5%; LaTME: 0%; p=0.400), as well as the length of the hospital stay (TaTME: 13.5 days; LaTME: 11 days; p=0.538), were similar in both groups. There were no statistically significant differences in the rates of positive circumferential resection margin (TaTME: 5%; LaTME: 3.3%; p=0.989) and positive distal resection margin (TaTME: 0%; LaTME: 3.3%; p=0.400), the completeness of the TME (TaTME: 100%; LaTME: 100%), and the number of lymph nodes harvested (TaTME: 15; LaTME: 15.5; p=0.882) between two groups. Conclusion: Transanal total mesorectal excision is a safe and feasible surgical procedure for middle/lower-third rectal cancer. (AU)

Surgery team building of 4K laparoscopic radical surgery for rectal cancer / 中华消化外科杂志

With the development of laparoscopic technology, minimally invasive surgery has been popularized. The proportion of laparoscopic surgery in the surgical operations has gradually increased, which has become the standard operation for rectal cancer. In recent years, 4K imaging technology has been applied in laparoscopy, which enhanced the presentation of details of surgical field, improved the sense of operation of surgeons, and promoted the progress of laparoscopic technology. Attaching importance to the construction of surgery team of 4K laparoscopic rectal cancer, enhancing the cooperation between teams and improving the learning ability of the team will contribute to the popularization and application of 4K laparoscopy in rectal cancer surgery.

Clinical efficacy of three-dimensional laparoscopic radical resection of rectal cancer with left colic artery preservation and natural orfice specimen extraction surgery / 中华消化外科杂志

Objective:To investigate the clinical efficacy of three-dimensional (3D) laparos-copic radical resection of rectal cancer with left colic artery preservation and natural orfice specimen extraction surgery (NOSES).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 186 patients with rectal cancer who were admitted to Henan Provincial People's Hospital from December 2018 to December 2019 were colleted. There were 120 males and 66 females, aged from 30 to 81 years, with a median age of 59 years. Patients underwent 3D laparoscopic radical resection of rectal cancer. Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up using outpatient examination or telephone interview was conducted to detect survival of patients and tumor recurrence up to January 2021. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers and percentages. Result:(1) Surgical situations: 186 patients with rectal cancer under-went 3D laparoscopic radical resection and postoperative with left colic artery preservation and NOSES. The operation time was (123±24)minutes, volume of intraoperative blood loss was (30±20)mL, the numer of lymph nodes dissected was 15±7. The time to postoperative first flatus, time to semiliquid food intake, time to postoperative out-of-bed activities were (2.3±0.7)days, (4.1±1.4)days, (2.9±1.0)days, respectively. The incidence of postoperative complications was 8.06%(15/186). The duration of postoperative hospital stay of 186 patients was (6.6±1.9)days and the treatment cost was (3.8±1.1) ten thousand yuan. Results of postoperative pathological examination showed 54 cases of low differentiated adenocarcinoma, 97 cases of moderate differentiated adenocarcinoma, 19 cases of high differentiated adenocarcinoma and 16 cases of mucinous adenocarcinoma. (2) Follow-up: 186 patients with rectal cancer were followed up for 13 to 24 months, with a median follow-up time of 13 months. During the follow-up, 18 patients had tumor recurrence or metastasis including 6 patients of death, 168 cases recovered well.Conclusion:3D laparoscopic radical resection of rectal cancer with left colic artery preservation and NOSES is safe and feasible.

Quality of life assessment in patients who have undergone oncologic resection of rectum: a retrospective, three arms, single centre, observational study

Background: Quality of life (QOL) analysis following cancer surgery is a sensitive issue among patients. The present study tried to find the status of these QOL parameters in patients who had undergone oncogenic resection of rectum.Methods: Patients were given the short form 36 (SF-36), The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the EORTC QLQ-C29 questionnaires to fill at three time points in their treatment (prior to surgery, 3 months and 6 months following surgery). The prospectively collected questionnaires were analysed retrospectively.Results: On comparing SF-36 questionnaire, there was significant improvement as we proceeded from baseline to first and second visit except for the energy level. On EORTC-30 questionnaire, there was significant improvement in all scales as we proceeded from baseline to first visit and then to second visit. On comparing EORTC-29 questionnaire, among all visits of abdominoperineal resection (APR), symptoms like pain and blood or mucus in stools significantly improved, low anterior resection (LAR) showed significant improvement in all 4 scales, high anterior resection (HAR) patients showed worst micturition complaints during first visit and gradually improving scores for other scales from baseline to first and second visit.Conclusions: The three-questionnaire used in the study comprehensively included all issues from general health after cancer surgery to problems faced by the patients specifically after various modalities of rectal surgery. Such studies should be planned routinely to assess comprehensive outcome of oncogenic surgeries.

Quality of Life After a Low Anterior Resection for Rectal Cancer in Elderly Patients

PURPOSE: Fecal incontinence is a major concern, and its incidence increases with age. Quality of life may decrease due to fecal incontinence after both sphincter-saving surgery and a rectal resection with a permanent stoma. This study investigated quality of life, with regard to fecal incontinency, in elderly patients after rectal-cancer surgery. METHODS: All patients who underwent elective rectal surgery with anastomosis for rectal cancer between December 2008 and June 2012 at two Dutch hospitals were eligible for inclusion. The Wexner and the fecal incontinence quality of life (FIQoL) scores were collected. Young ( or =70 years of age) patients were compared. RESULTS: Seventy-nine patients were included, of whom 19 were elderly patients (24.1%). All diverting stomas that had been placed (n = 60, 75.9%) had been closed at the time of the study. There were no differences in Wexner or FIQoL scores between the young and the elderly patients. Also, there were no differences between patients without a diverting stoma and patients in whom bowel continuity had been restored. Elderly females had significantly worse scores on the FIQoL subscales of coping/behavior (P = 0.043) and depression/self-perception (P = 0.004) than young females. Elderly females scored worse on coping/behavior (P = 0.010) and depression/self-perception (P = 0.036) than elderly males. Young and elderly males had comparable scores. CONCLUSION: Quality of life with regard to fecal incontinency is worse in elderly females after sphincter-preserving surgery for rectal cancer. Patients should be informed of this impact, and a definite stoma may be considered in this patient group.

Usefulness of Anorectal Manometry for Diagnosing Continence Problems After a Low Anterior Resection

PURPOSE: For several decades, the low anterior resection (LAR) with total mesorectal excision (TME) has been the gold standard for treating patients with rectal cancer. Up to 90% of patients undergoing sphincter-preserving surgery will have changes in bowel habits, so-called 'anterior resection syndrome.' This study examined patients' continence after a LAR for the treatment of rectal cancer. METHODS: This prospective study was performed between September 2014 and August 2015 at the National Cancer Institute and included 30 patients who underwent anorectal manometry preoperatively and at 3 and 4 months after a LAR, but 10 were excluded from further evaluation for various reasons. Wexner score was recorded preoperatively and 4 months after LAR (1 month after ileostomy repair). RESULTS: Postoperatively, 70% of patients complained of some degree of soiling (incontinence to liquid stool), and 30% experienced urgent defecation. Four months after surgery, these symptoms had somewhat abated. The anal resting pressure and the maximum squeezing pressure did not change significantly. Rectal capacity and compliance were reduced in all patients. The majority of patients demonstrated manometric anorectal changes and clinical anorectal function disorders during the first 4 months after surgery. The Wexner scores and the manometric findings showed no correlation. CONCLUSION: Many patients undergoing a LAR with TME for the treatment of rectal cancer experience some degree of incontinence postoperatively. Anorectal manometry may be used as an additional tool for evaluating problems with continence after a LAR. No correlation between the Wexner score and the manometric findings was observed.

Risk Factors and Oncologic Impact of Anastomotic Leakage after Rectal Cancer Surgery

PURPOSE: Anastomotic leakage (AL) is a serious and life-threatening complication following rectal cancer surgery. The impact on long-term oncologic outcome in patients with AL is not clear. The aim of this retrospective study was to evaluate the risk factors of AL and its impact on long-term prognosis after rectal cancer surgery. METHODS: We investigated 1,391 patients who underwent primary resection and anastomosis for rectal cancer between January 1997 and August 2003. Operations were performed as follows: AR (n=164), LAR (n=898), uLAR (n=329). Standard procedures in our clinic were mesorectal excision according to tumor location and autonomic nerve preservation. Median follow-up period was 40.1 months (2~96 months). RESULTS: AL rate was 2.5% (n=35). Gender (male), age (>60 years) and uLAR were independent risk factors in multivariate analysis (HR: 3.03, 95% CI: 1.18~7.22; HR: 2.42, 95% CI: 1.12~7.83; HR: 2.68, 95% CI: 1.08~7.09, respectively). Local recurrence in the AL group was significantly higher than that in the non-AL group (P<0.05), but there was no significant difference in multivariate analysis (P=0.14). Systemic recurrence between both groups was not statistically different. The 5-year overall survival rate was significantly lower in the AL group than in the non-AL group (55.1% vs 74.1%, P<0.05) and the cancer- specific survival rate was lower in the AL group than in the non-AL group (63.0% vs 78.3%, P=0.05). CONCLUSIONS: Age, gender, and anastomotic level were risk factors for AL after rectal cancer surgery and anastomotic leakage was associated with a poor survival.

The Effect of Hyaluronate Membrane on Prevention of Adhesion after Rectal Cancer Surgery: a Prospective Study

PURPOSE: The aim of this study was to evaluate the efficacy of using a Hyaluronate (HA) bioresorbable membrane (SeprafilmTM, Genzyme Corp., Cambridge, MA) to prevent adhesion after rectal cancer surgery. METHODS: We recruited 362 rectal cancer patients who underwent a curative resection between April 2001 and December 2002. We excluded patients with a previous operation history, a stoma procedure, a multivisceral resection, an extended lymphadenectomy, a total colectomy, or a pouch procedure. An adhesive ileus was defined as a symptomatic, radiological intestinal obstruction without evidence of recurrence. RESULTS: We placed the HA membrane under the midline incision in 153 patients. There was no difference between the groups regarding demographic findings and clinicopathological findings, including locations of the tumors, surgery performed, AJCC stage, and adjuvant treatment. While only 1 (0.7%) patient of the HA group experienced an adhesive ileus, 13 (6.2%) cases of adhesion were identified in the control group (P=0.008). Every patient, except 1 in the control group, underwent conservative management. CONCLUSIONS: A Hyaluronate membrane may be effective in preventing an adhesive ileus after rectal cancer surgery. However, a prospective, randomized, double-blind study is needed.

Necrotizing Fasciitis of Perineum after Surgery and Radiation Therapy for Rectal Cancer

Necrotizing fasciitis is a rare disease characterized by rapidly progressive soft tissue infection primarily involving the superficial fascia and is associated with significant morbidity and mortality. Necrotizing fasciitis of the genitalia and the perineum, also known as Fournier's gangrene, usually occurs after local trauma, perirectal or perineal infections, and complicated surgery, such as circumcision and herniorraphy. The lack of initial external clinical signs, because the process begins in the deep subcutaneous tissue, make early diagnosis and adequate surgical management difficult. The progression of the disease is often fulminant, and the prognosis hinges on accurate diagnosis and immediate surgical debridement. The present case report documents the rare development of fulminant necrotizing fasciitis associated with a rectal cancer surgery and radiation therapy.

Clinical Characteristics of Inguinal Hernia Following Rectal Cancer Surgery

PURPOSE: The anatomic and physiologic changes after rectal cancer surgery was suggested to be a cause of inguinal hernia. But, there are only few reported cases about the inguinal hernia following rectal cancer surgery. The aim of this study is to verify risk factors and surgical techniques to prevent inguinal hernia following rectal cancer surgery. METHODS: Out of 1226 patients who underwent operations at the Department of Surgery, Asan Medical Center, between the period from June 1989 to July 1999, 12 patients who had developed inguinal hernia and their medical records were reviewed retrospectively regarding the clinical characteristics. RESULTS: The median duration of hernia following rectal cancer surgery was 12 (3-36) months. The median age was 63 (36-74) years with eight of them more than seventh decades of their life. All patients had male sex. Three of them were overweighted. Five cases had hernias on the left side, six on the right, and one case on both side. All patients had indirect inguinal hernia. Three cases had preoperative symptoms of bowel obstruction. The operations for rectal cancer were low anterior resection in eight cases, ultralow anterior resection in three cases, and abdominoperineal resection in one case. The complications in rectal cancer surgery were found in six cases. Six cases had the advanced stage. A postoperative radiation therapy was applied in five cases. Five cases had the coexisting diseases. CONCLUSIONS: Male sex and old age would be related with occuring inguinal hernia after rectal cancer surgery and, it would be necessary to give a special attention to the patients who have these factors, although the present study could not show the definite correlation between inguinal hernia and rectal cancer surgery due to a small number of cases.

Anastomotic Stricture after Colorectal Stapled Anastomosis

INTRODUCTION: Stapled anastomosis in the rectal cancer surgery has been already proven as a safe technique, maintaing secure suture and saving times compared to handsewn anastomosis. With the advancement of stapling device, the incidence of anastomotic leakage has decreased significantly. However, developement of anastomotic stricture has become a major postoperative complication. PURPOSE: An analysis of the clinical features and the predisposing factors of anastomotic stricture was made to identify its pathogenesis and to determine adequate procedure. METHODS: We analyzed 49 patients (8.1%) with the rectal stricture among 608 patients, undergone stapled anastomosis for the rectal cancer surgery at Asan Medical Center from Jan 1993 to Dec 1998. Rectal stricture was defined when index finger or colonoscope could not pass the anastomotic site (high grade), or could pass with difficulty(low grade). RESULTS: Underlying general diseases, e.g., DM, hypertension and cardiovascular disease was associated more frequently in patients with anastomotic stricture (20.4%) than patients without (10.8%) (P<0.05). The rate of postoperative major complications in patients with stricture was 22.4%, while that of anastomotic leakage was 6.1%. Development of anastomotic stricture was not associated with operative methods, age, anastomosis level, and postoperative radiotherapy. In patients with stricture, 34 patients (69.4%) were asymptomatic, and 15 patients were symptomatic. In treating symptomatic rectal stricture, only five patients performed dilation manually or by the Hegar dilator. CONCLUSIONS: Rectal stricture after stapled anastomosis might be associated with underlying diseases, and correlated with prolonged sanguinous drainage and ileus. Meticulous management of underlying disease and complete hemostasis during operation appear to be important to reduce the rate of rectal stricture.