Construction of a nomogram model to predict technical difficulty in performing laparoscopic sphincter-preserving radical resection for rectal cancer

BACKGROUND Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities.Therefore,it is essential for colorectal surgeons to have a comprehensive understanding of pelvic structure prior to surgery and anticipate potential surgical difficulties.AIM To evaluate predictive parameters for technical challenges encountered during laparoscopic radical sphincter-preserving surgery for rectal cancer.METHODS We retrospectively gathered data from 162 consecutive patients who underwent laparoscopic radical sphincterpreserving surgery for rectal cancer.Three-dimensional reconstruction of pelvic bone and soft tissue parameters was conducted using computed tomography(CT)scans.Operative difficulty was categorized as either high or low,and multivariate logistic regression analysis was employed to identify predictors of operative difficulty,ultimately creating a nomogram.RESULTS Out of 162 patients,21(13.0%)were classified in the high surgical difficulty group,while 141(87.0%)were in the low surgical difficulty group.Multivariate logistic regression analysis showed that the surgical approach using laparoscopic intersphincteric dissection,intraoperative preventive ostomy,and the sacrococcygeal distance were independent risk factors for highly difficult laparoscopic radical sphincter-sparing surgery for rectal cancer(P<0.05).Conversely,the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance was identified as a protective factor(P<0.05).A nomogram was subsequently constructed,demonstrating good predictive accuracy(C-index=0.834).CONCLUSION The surgical approach,intraoperative preventive ostomy,the sacrococcygeal distance,and the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance could help to predict the difficulty of laparoscopic radical sphincter-preserving surgery.

Quality of life after laparoscopic vs open sphincter-preserving resection for rectal cancer

AIM: To compare quality of life (QoL) outcomes in Chinese patients after curative laparoscopic vs open surgery for rectal cancer. METHODS: Eligible Chinese patients with rectal cancer undergoing curative laparoscopic or open sphincterpreserving resection between July 2006 and July 2008 were enrolled in this prospective study. The QoL outcomes were assessed longitudinally using the validated Chinese versions of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQCR38 questionnaires before surgery and at 4, 8, and 12 mo after surgery. The QoL scores at the different time points were compared between the laparoscopic and open groups. A higher score on a functional scale indicated better functioning, whereas a higher score on a symptom scale indicated a higher degree of symptoms.RESULTS: Seventy-four patients (49 laparoscopic and 25 open) were enrolled. The two groups of patients were comparable in terms of sociodemographic data, types of surgery, tumor staging, and baseline mean QoL scores. There was no significant decrease from baseline in global QoL for the laparoscopic group at different time points, whereas the global QoL was worse compared to baseline beginning at 4 mo but returned to baseline by 12 mo for the open group (P = 0.019, Friedman test). Compared to the open group, the laparoscopic group had significantly better physical (89.9±1.4 vs 79.2±3.7, P = 0.016), role (85.0±3.4 vs 63.3±6.9, P = 0.005), and cognitive (73.5±3.4 vs 50.7±6.2, P = 0.002) functioning at 8 mo, fewer micturition problems at 4-8 mo (4 mo: 32.3±4.7 vs 54.7±7.1, P = 0.011; 8 mo: 22.8±4.0 vs 40.7±6.9, P = 0.020), and fewer male sexual problems from 8 mo onward (20.0±8.5 vs 76.7±14.5, P = 0.013). At 12 mo after surgery, no significant differences were observed in any functional or symptom scale between the two groups, with the exception of male sexual problems, which remained worse in the open group (29.2±11.3 vs 80.0±9.7, P = 0.026). CONCLUSION: Laparoscopic sphincter-preserving resection for rectal cancer is associated with better preservation of QoL and fewer male sexual problems when compared with open surgery in Chinese patients. These findings, however, should be interpreted with caution because of the small sample size of the study.

Application of laparoscopic total mesorectal excision combined with sphincter-preserving surgery in low or ultralow rectal cancer

This study aimed to investigate the influence of laparoscopic total mesorectal excision combined with sphincter-preserving surgery on the postoperative defecation function,urinary function and sexual function in low or ultralow rectal cancer.A retrospective study was undertaken on 107 patients(65 laparoscopic resection and 42 laparoctomic resection)with rectal cancer undergoing laparoscopic or open laparoscopic total mesorectal excision combined with sph incter-preserving surgery from April 2009 to April 2013.The quality of life outcomes of all patients,including defection,urinary and sexual function,were assessed at 6,12 and 24 months after operation.Gastrointestinal quality of life index(GQOLI)was used to evaluate the fecal incont inence and bowel dysfunction.Urinary and sexual functions were studied by means of questionnaires on the basis of the international prostatic symptom score(IPSS)and international index of erectile function(IEF),respectively.In laparoscopic surgery group,there were two cases of anastomotic leakage,three cases of anast omotic strict ure,seven cases of local recurrence,ten cases of hepatic metastasis and five cases of lung metastasis.The satisfaction rates of patients about their defe-cation function reached 60.3%(35/58,84.5%(49/58)and 913%(53/58)at6,12,and 24 months follow-up,respectively.The assessment after one year showed that the overall incidence of uri-nary dysfunction was 10.7%(7/65);Among male patients,18.4%(7/36)sufered from erectile dysfunction and 27.8%(10/36)sufered from ejaculatory dysfunction;65.5%(19/29)female patients investigated were satisfied with their postoperative sexual life.In open surgery group,there were two cases of anastomotic leakage,two cases of anastomotic stricture,nine cases of local recurrence,ten cases of hepatic metastasis and seven cases of kung metastasis.The satisfaction rates of patients about their defecation function were 56.4%(22/39),82.1%(32/39)and 94.8%(37/39)at 6,12,and 24 months follow-up,respectively.The assessment after one year showed that the overall incidence of urinary dysfunction was 11.9%(5/42);25%(4/16)male patients suffered from erectile dysfunction and 313%(5/16)sufered from ejaculatory dysfunction;69.2%(19/26)female patients investigated were satisfied of their postoperative sexual life.There was no statistic difference in the two groups.Laparoscopic total mesorectal excision combined with sphincter-preserving surgery in low or ultralow rectal carcinoma is safe and pract icable.It can be helpful for enhancing the probability of anus reservation,and obtains satisfactory defecation,sexual and urinary functions.

Risk factors for adverse outcome in low rectal cancer

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 Aff iliated 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 signif icantly 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 identif ied as an independent risk factor for survival.

Five-year oncologic outcomes and prognostic factors for locally advanced low rectal cancer after low anterior resection

Objective： The aim of the study is to investigate the longterm oncologic outcomes including local recurrence, distant metastases and overall survival （OS） for patients with low rectal cancer underwent low anterior resection （LAR） with total mesorectal excision （TME）, and to analyze the prognostic factors for them. Methods： Between January 2001 and December 2009, 147 patients with clinical stage II and III rectal cancers located 3-6 cm from the anal verge underwent LAR with TME without temporary diverting stoma. The median distal resection margin （DRM） was 1.0 （range, 0.3-5） cm. Anastomostic leakage occurred in 29 （19.7%） patients. Thirty patients received surgery alone, 20 patients received preoperative chemoradiotherapy （CRT）, 43 patients received postoperative CRT, and adjuvant chemotherapy was administered for 108 patients. The median cycle of adjuvant chemotherapy was 6 （range, 2-20） cycles. The median followup was 74.8 （range, 30.1-146.3） months. Results： In all patients, 5-year recurrence-free survival （RFS）, disease-free survival （DFS） and OS were 70.4%, 54.2% and 60.5%, respectively. Forty-three （29.3%） patients suffered local recurrence. Patients received preoperative CRT with a downstaging yp0/1 who had a better 5-year RFS, DFS and OS, which were 100%, 90.9%, and 90.9%, respectively. For patients with pathologic stage Ⅱ and stage Ⅲ, the 5-year RFS, DFS, and OS were 79.2% and 60.1%, 67.9% and 39.1%, 72.1% and 48.2%, respectively. On multivariable analysis, RFS was associated with anostomostic leakage, DFS was associated with anastomostic leakage and pathologic N stage, and OS was associated with anastomostic leakage, pathologic N and T stage. For patients with anastomostic leakage, the 5-year RFS, DFS, and OS were 51.7%, 32.4%, and 38.3%, respectively, which were worse than that for patients without anastomostic leakage, the latter were 75.2%, 59.7%, 65.7%, respectively （P 〈 0.05）. DRM and radiotherapy were associated with RFS on univariable analysis （P 〈 0.05）, but not on multivariable analysis. Tumor grade was prognostic factors for RFS and OS on univariable analysis, but not on multivariable analysis. The other factors including sex, age, tumor size and adjuvant chemotherapy were not associated with RFS, DFS and OS on univariable analysis. Conclusion： For patients with low rectal caner underwent LAR and TME, the long-term oncologic outcomes were satisfactory for patients with stage yp0/1, but not for patients with pathologic stage II1. Anastomositic leakage negatively affect long-term oncologic outcomes. Radiotherpy, adjuvant chemotherapy and distal resection margin were not associated with long-term outcomes.

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries(SPS)for rectal cancer.The bowel dysfunction usually manifests in the form of low anterior resection syndrome(LARS),which has a negative impact on the patients'quality of life.This study reviewed the LARS after SPS,its mechanism,risk factors,diagnosis,prevention,and treatment based on previously published studies.Adequate history taking,physical examination of the patients,using validated questionnaires and other diagnostic tools are important for assessment of LARS severity.Treatment of LARS should be tailored to each patient.Multimodal therapy is usually needed for patients with major LARS with acceptable results.The treatment includes conservative management in the form of medical,pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation.If this treatment failed,fecal diversion may be needed.In conclusion,Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS.Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.

Neoadjuvant therapy followed by local excision and two-stage total mesorectal excision:a new strategy for sphincter preservation in locally advanced ultra-low rectal cancer

Background:With the increased usage of neoadjuvant chemoradiotherapy,improved surgical technique and stapling devices,sphincter-preserving resection has become more frequent for patients with rectal cancer.However,as for locally advanced ultra-low rectal cancer,sphincter-preservation is still facing an enormous challenge.Objective:To introduce an NLT strategy of sphincter-preservation-neoadjuvant therapy(NT)followed by local excision(LE)and two-stage total mesorectal excision(TME)-into the treatment of locally advanced ultra-low rectal cancer(lesions with anal sphincter invasion).Methods:From October 2010 to October 2011,nine patients with locally advanced rectal cancer located less than 3 cm from the anal verge were treated by the NLT strategy.All patients had shown good clinical response to NT.The LE procedure was carried transanally 6-8 weeks after completion of the NT.TME was performed to dissect mesorectal lymph nodes 4-6 weeks after LE.Results:Of the nine patients,the lesion was assessed as T2 in two,T3 in five,and T4 in two before NT,and lymph node metastasis was detected in five patients.The median distance from the tumor to the anal verge was 2.5 cm(range:1-3 cm).The median follow-up was 27 months(range:24-34 months).No distant metastasis was detected.Only one patient(11.1%)developed local recurrence at 12 months post-operatively and then underwent abdomino-perineal resection.The remaining eight patients had preserved long-term continence and the median Wexner score at two years post-operation was 4(range:2-6).Conclusion:The new NLT strategy can achieve sphincter-preservation in some patients with ultra-low rectal cancer,with favorable oncological outcome and preservation of normal anal sphincter function.