Laparoscopic total mesorectal excision following long course chemoradiotherapy for locally advanced rectal cancer
Laparoscopic total mesorectal excision (TME) of locally advanced rectal cancer after long-course chemoradiotherapy (LCRT) is surgically and oncologically challenging. We have assessed the feasibility, timing, and short-term oncological outcome of laparoscopic TME after LCRT.
Between 2004 and 2006, 30 patients were selected for LCRT based on clinical examination and MRI. Patients received 3/4 field radiotherapy, 45–50.4 Gy in 25–28 fractions during 5 weeks with either 5-fluorouracil or Uftoral. Clinical assessments were made 4 weeks after completion of radiotherapy and then 2 weekly with sequential 4 weekly MRI, to individualize the timing of surgery at maximal response. Laparoscopic TME was performed using a standard technique.
Thirty patients received LCRT and 26 patients (21 men; median age, 63 years) underwent laparoscopic TME at 11 weeks (median) after LCRT. Median operating time was 270 min. Sixteen patients had LAR and ten had APR. There were three conversions. Three patients developed anastomotic leak (18.7%): one was managed conservatively and one patient died of septicemia. Morbidity was seen in 19% of patients. There were 25 (96%) R0 resections with a complete response in 5 (19%) cases and microscopic tumor in lakes of mucin (Tmic) in another 6 (23%). Two patients (7.6%) developed local recurrence (median follow up, 34 months). The median time interval between radiotherapy and surgery was 11 (range, 7–13) weeks, which was based on serial MRI scans after LCRT.
Laparoscopic TME after LCRT is feasible and safe both oncologically and surgically. Serial MRI helps to determine the optimum timing of surgery.
KeywordsLaparoscopic total mesorectal excision Locally advanced rectal cancer Long-course chemoradiotherapy
The authors wish to acknowledge the support of Mrs Jane Bradley-Hendricks and Professor John Norton in writing this manuscript.
R. W. Motson, J. S. Khan, T. H. A. Arulampalam, R. C. T Austin, N. Lacey, and B. Sizer have no conflicts of interest or financial ties to disclose.
- 4.Habr-Gama A, Perez RO, Nadalin W, Nahas SC, Ribeiro U Jr, Silva E, Sousa AH Jr, Campos FG, Kiss DR, Gama-Rodrigues JA (2005) Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg 9(1):90–99PubMedCrossRefGoogle Scholar
- 6.Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, Allen PK, Lynch PM, Glober G, Wolff R, Rich TA, Skibber J (1999) Tumor down staging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the MD Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 44(5):1027–1038PubMedCrossRefGoogle Scholar
- 10.Rodríguez-Ramírez SE, Uribe A, Ruiz-García EB, Labastida S, Luna-Pérez P (2006) Risk factors for anastomotic leakage after preoperative chemoradiation therapy and low anterior resection with total mesorectal excision for locally advanced rectal cancer. Rev Invest Clin 58(3):204–210PubMedGoogle Scholar
- 11.Marijnen CA, Kapiteijn E, van de Velde CJ, Martijn H, Steup WH, Wiggers T, Kranenbarg EK, Leer JW, Cooperative Investigators of the Dutch Colorectal Cancer Group (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20(3):817–825PubMedCrossRefGoogle Scholar
- 16.Habr-Gama A, Perez R, Proscurshim I, Campos F, Nadalin W, Kiss D, Gama-Rodrigues J et al (2006) Patterns of failure and survival for non-operative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg 10(10):1319–1328PubMedCrossRefGoogle Scholar
- 17.Parvais A, Lawes D, Gilani S, Arulampalam T, Austin R, Motson R (2006) Outcome following laparoscopic rectal resections for cancer: experience with 125 consecutive cases. Surg Endosc 20(Suppl 1):S253Google Scholar
- 29.Sizer B, Arulampalam T, Austin R, Basu D, Lacey N, Menzies D, Motson R (2007) Individualizing the interval between neoadjuvant chemoradiation with uracil-tegafur (UFT) and total mesorectal excision in magnetic resonance imaging defined poor risk rectal cancer. J Clin Oncol 25(18S):14557Google Scholar
- 30.Uzcudun AE, Batlle JF, Velasco JC, Sánchez Santos ME, Carpeño Jde C, Grande AG, Juberías AM, Piñeiro EH, Olivar LM, García AG (2002) Efficacy of preoperative radiation therapy for resectable rectal adenocarcinoma when combined with oral tegafur-uracil modulated with leucovorin: results from a phase II study. Dis Colon Rectum 45(10):1349–1358PubMedCrossRefGoogle Scholar
- 35.Miyajima N, Fukunaga M, Hasegawa H et al (2009) Results of a multicentre study of 1,057 cases of rectal cancer treated by laparoscopic surgery. Surg Endosc 129:674–680Google Scholar