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Local recurrence after curative resection of cancer of the rectum without total mesorectal excision

  • Original Contributions
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Diseases of the Colon & Rectum

Abstract

PURPOSE: The aim of this article was to examine local recurrence after curative resection for carcinoma of the rectum in which the surgical technique of total mesorectal excision was not performed. METHODS: A single surgeon managed the patients and the data collected prospectively. Total excision of the distal mesorectum was not performed in the upper third or mid rectum. RESULTS: From 1969 to 1993 curative resections were performed in 549 patients, of which 17 died postoperatively, leaving 532 for analysis. Sphincter-saving resection was performed in 468 patients (88 percent) and abdominoperineal excision in 58 (10.9 percent). The pathology stages (Dukes) were A, 158 (29.7 percent); B, 184 (34.7 percent); and C, 190 (35.7 percent). Five hundred seventeen patients (97.2 percent) were followed up for a minimum of five years. The median period of follow-up was 82 months. Local recurrence confined to the pelvis occurred in 17 patients, and local recurrence associated with distant metastases occurred in 24 patients. The total five-year local recurrence rate was 7.6 percent. Local recurrence was increased in Stage C tumors (P=<0.0001). Diathermy dissection in the pelvis was associated with a decreased local recurrence rate (P=0.023). The five-year survival rate in curative resections was 72.5 percent. CONCLUSIONS: It is essential that articles presenting local recurrence rates should include both local recurrence in isolation and that which occurs with distant metastases. Although total mesorectal excision for rectal cancer was not performed in this study, the local recurrence rate is not materially different from that in several articles where total mesorectal excision has been used. Whether the distal mesorectum needs to be pursued in mid-rectal cancer is not yet proven.

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References

  1. Holm T, Cedermark B, Rutqvist L-E. Local recurrence of rectal adenocarcinoma after ‘curative’ surgery with and without preoperative radiotherapy. Br J Surg 1994;81:452–5.

    PubMed  Google Scholar 

  2. Hill GL, Rafique M. Extrafascial excision of the rectum for rectal cancer. Br J Surg 1998;85:809–12.

    Article  PubMed  Google Scholar 

  3. Goldberg SM, Klas JV. Total mesorectal excision in the treatment of rectal cancer: a view from the USA. Semin Surg Oncol 1998;15:87–90.

    Article  PubMed  Google Scholar 

  4. Hermanek P. Impact of surgeon's technique on outcome after treatment of rectal carcinoma. Dis Colon Rectum 1999;42:559–62.

    PubMed  Google Scholar 

  5. Wiig JN, Carlsen E, Søreide O. Mesorectal excision for rectal cancer: a view from Europe. Semin Surg Oncol 1998;15:78–86.

    Article  PubMed  Google Scholar 

  6. McCall JL, Cox MR, Wattchow DA. Analysis of local recurrence rates after surgery alone for rectal cancer. Int J Colorectal Dis 1995;10:126–32.

    Article  PubMed  Google Scholar 

  7. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer. The Basingstoke experience of total mesorectal excision 1978–1997. Arch Surg 1998;133:894–9.

    Article  PubMed  Google Scholar 

  8. Arbman G, Nilsson E, Hallböök O, Sjödahl R. Local recurrence following total mesorectal excision for rectal cancer. Br J Surg 1996;83:375–9.

    PubMed  Google Scholar 

  9. Dixon AR, Maxwell WA, Thornton Holmes J. Carcinoma of the rectum: a 10-year experience. Br J Surg 1991;78:308–11.

    PubMed  Google Scholar 

  10. Isbister WH. Basingstoke revisited. Aust N Z J Surg 1990;60:243–6.

    PubMed  Google Scholar 

  11. Fazio VW, Surgery of the colon and rectum. Am J Gastroenterol 1994;89(Suppl 8):S106–15.

    PubMed  Google Scholar 

  12. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995;181:335–46.

    PubMed  Google Scholar 

  13. Eu K-W, Seow-Choen F, Ho JM, Ho YH, Leong AF. Local recurrence following rectal resection for cancer. J R Coll Surg Edinb 1998;43:393–6.

    PubMed  Google Scholar 

  14. Hall NR, Finan PJ, Al-Jaberi T, et al. Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent: predictor of survival but not local recurrence? Dis Colon Rectum 1998;41:979–83.

    Article  PubMed  Google Scholar 

  15. Bokey EL, Ojerskog B, Chapuis PH, Dent OF, Newland RC, Sinclair G. Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 1999;86:1164–70.

    Article  PubMed  Google Scholar 

  16. Marsh PJ, James RD, Schofield PF. Definition of local recurrence after surgery for rectal carcinoma. Br J Surg 1995;82:465–8.

    PubMed  Google Scholar 

  17. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 1982;69:613–6.

    PubMed  Google Scholar 

  18. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986;2:1479–82.

    Article  Google Scholar 

  19. American Society of Colon, and Rectal Surgeons Standards Task Force. Practice parameters for the treatment of rectal carcinoma. Dis Colon Rectum 1993;36:989–1006.

    Google Scholar 

  20. Royal College of Surgeons of England, Association of Coloproctology of Great Britain, and Ireland. Guidelines for the management of colorectal cancer. 1996; p25.

  21. Heald RJ. Total mesorectal excision is optimal surgery for rectal cancer: a Scandinavian consensus. Br J Surg 1995;82:1297–9.

    PubMed  Google Scholar 

  22. Beart RW Jr. Mesorectal excision for rectal carcinoma: the new standard? Adv Surg 1999;32:193–203.

    PubMed  Google Scholar 

  23. McDermott FT, Hughes ES, Pihl E, Johnson WR, Price AB. Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients. Br J Surg 1985;72:34–7.

    PubMed  Google Scholar 

  24. Cawthorn SJ, Parums DV, Gibbs NM, et al. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer. Lancet 1990;335:1055–9.

    Article  PubMed  Google Scholar 

  25. Macfarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;341:457–60.

    Article  PubMed  Google Scholar 

  26. Abulafi AM, Williams NS. Local recurrence of colorectal cancer: the problems, mechanisms, management and adjuvant therapy. Br J Surg 1994;81:7–19.

    PubMed  Google Scholar 

  27. Jatzko GR, Jagoditsch M, Lisborg PH, Denk H, Klimpfinger M, Stettner HM. Long term results of radical surgery for rectal cancer: multivariate analysis of prognostic factors influencing survival and local recurrence. Eur J Surg Oncol 1999;25:284–91.

    Article  PubMed  Google Scholar 

  28. Morson BC, Vaughan EG, Bussey HJ. Pelvic recurrence after excision of rectum for carcinoma. BMJ 1963;2:13–8.

    Google Scholar 

  29. Moosa AR, Ree PC, Marks JE, Levin B, Platz CE, Skinner DB. Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum and rectosigmoid. Br J Surg 1975;62:727–30

    PubMed  Google Scholar 

  30. Pilipshen SJ, Heilweil M, Quan SH, Sternberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer 1984;53:1354–62.

    PubMed  Google Scholar 

  31. Bentzen SM, Balslev I, Piederson M, et al. Time to locoregional recurrence after resection of Dukes B and C colorectal cancer with or without adjuvant postoperative radiotherapy: multivariate regression analysis. Br J Cancer 1992;65:102–7.

    PubMed  Google Scholar 

  32. Vernava AM, Moran M, Rothenberger DA, Wong WD. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 1992;175:333–6.

    PubMed  Google Scholar 

  33. Karanjia ND, Schache DJ, North WR, Heald RJ. ‘Close shave’ in anterior resection. Br J Surg 1990;77:510–2.

    PubMed  Google Scholar 

  34. Gérard A, Buyse M, Nordlinger B. Preoperative radiotherapy as adjuvant treatment in rectal cancer. Ann Surg 1988;208:606–14.

    PubMed  Google Scholar 

  35. Goldberg PA, Nicholls RJ, Porter NH, Love S, Grimsey JE. Long-term results of a randomised trial of short-course low-dose adjuvant preoperative radiotherapy for rectal cancer: reduction in local treatment failure. Eur J Cancer 1994;30A:1602–6.

    Article  PubMed  Google Scholar 

  36. Cedermark B, for the Stockholm Colorectal Cancer Study Group. The Stockholm II trial on preoperative short-term radiotherapy in operable rectal carcinoma—a prospective randomised trial [abstract]. Proc Am Soc Clin Oncol 1994;14:198.

    Google Scholar 

  37. Medical Research Council Rectal Cancer Working Party. Randomised trial of surgery alone versus radiotherapy followed by surgery for potentially operable locally advanced rectal cancer. Lancet 1996;348:1605–10.

    Google Scholar 

  38. Medical Research Council Rectal Cancer Working Party. Randomised trial of surgery alone versus surgery followed by radiotherapy for mobile cancer of the rectum. Lancet 1996;348:1610–4.

    Google Scholar 

  39. McLeod RS. Symposium on rectal cancer: 2. Local recurrence after surgery for rectal cancer. Can J Surg 1997;40:353–7.

    PubMed  Google Scholar 

  40. Porter GA, Soskolne CL, Yakimets WW, Newman SC. Surgeon-related factors and outcome in rectal cancer. Ann Surg 1998;227:157–67.

    Article  PubMed  Google Scholar 

  41. Zaheer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D. Surgical treatment of adenocarcinoma of the rectum. Ann Surg 1998;227:800–11.

    Article  PubMed  Google Scholar 

  42. Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 1994;344:707–11.

    Article  PubMed  Google Scholar 

  43. Moriya Y, Sugihara K, Akasu T, Fujita S. Patterns of recurrence after nerve-sparing surgery for rectal adenocarcinoma with special reference to loco-regional recurrence. Dis Colon Rectum 1995;38:1162–8.

    Article  PubMed  Google Scholar 

  44. McCall JL. Total mesorectal excision: evaluating the evidence. Aust N Z J Surg 1997;67:599–602.

    PubMed  Google Scholar 

  45. Chapuis PH, Bokey EL. Where are we now with adjuvant therapy for rectal cancer? Aust N Z J Surg 1997;67:588–90

    PubMed  Google Scholar 

  46. Penfold JC. A comparison of restorative resection of carcinoma of the middle third of the rectum with abdominoperineal excision. Aust N Z J Surg 1974;44:354–6.

    PubMed  Google Scholar 

  47. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patient's survival. Br J Surg 1983;70:150–4.

    PubMed  Google Scholar 

  48. Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg 1983;198:159–63.

    PubMed  Google Scholar 

  49. Carlsen E, Schlichting E, Guldvog I, Johnson E, Heald RJ. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg 1998;85:526–9.

    Article  PubMed  Google Scholar 

  50. Fazio VW. Cancer of the rectum—sphincter-saving operation. Stapling techniques. Surg Clin North Am 1988;68:1367–82.

    PubMed  Google Scholar 

  51. Vignali A, Fazio VW, Lavery IC, et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients. J Am Coll Surg 1997;185:105–13.

    Article  PubMed  Google Scholar 

  52. Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 1998;85:355–8.

    Article  PubMed  Google Scholar 

  53. Hallböök O, Johansson K, Sjödahl R. Laser Doppler blood flow measurement in rectal resection for carcinoma—comparison between the straight and colic J pouch reconstruction. Br J Surg 1996;83:389–92.

    PubMed  Google Scholar 

  54. Hallböök O, Påhlman L, Krog M, Wexner SD, Sjödahl R. Randomized comparison of straight and colonic J. pouch anastomosis after low anterior resection. Ann Surg 1996;224:58–65.

    Article  PubMed  Google Scholar 

  55. Wexner SD, Alabaz O. Anastomotic integrity and function: the role of the colonic J pouch. Semin Surg Oncol 1998;15:91–100.

    Article  PubMed  Google Scholar 

  56. Lopez-Kostner F, Lavery IC, Hool GR, Rybicki LA, Fazio VW. Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery 1998;124:612–8.

    Article  PubMed  Google Scholar 

  57. Sauer I, Bacon HE. Influence of lateral spread of cancer of the rectum on radicability of operation and prognosis. Am J Surg 1951;81:111–20.

    Article  PubMed  Google Scholar 

  58. Anderberg B, Enblad P, Sjödahl R, Wetterfors J. The EEA-stapling device in anterior resection for carcinoma of the rectum. Technique and early recurrences. Acta Chir Scand 1983;149:99–103.

    PubMed  Google Scholar 

  59. Chan KW, Boey J, Wong SK. A method of reporting radial invasion and surgical clearance of rectal carcinoma. Histopathology 1985;9:1319–27.

    PubMed  Google Scholar 

  60. Quirke P, Dixon MF, Durdey P, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 1986;2:996–9.

    Article  PubMed  Google Scholar 

  61. Quirke P, Dixon MF. The prediction of local recurrence in rectal adenocarcinoma by histopathological examination. Int J Colorectal Dis 1988;3:127–31.

    Article  PubMed  Google Scholar 

  62. Newland RC, Chapuis PH, Dent OF, Bokey EL. Total mesorectal excision is optimal surgery for rectal cancer: a Scandinavian consensus [letter]. Br J Surg 1996;83:427–8.

    Google Scholar 

  63. Mori T, Takahashi K, Yasuno M. Radical resection with autonomic nerve preservation and lymph node dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbecks Arch Surg 1998;383:409–15.

    Article  PubMed  Google Scholar 

  64. Moreira LF, Hizuta A, Iwagaki H, et al. Lateral lymph node dissection for rectal cancer below the peritoneal reflection. Br J Surg 1994;81:293–6.

    PubMed  Google Scholar 

  65. Reynolds JV, Joyce WP, Dolan J, Sheahan K, Hyland JM. Pathological evidence in support of total mesorectal excision in the management of rectal cancer. Br J Surg 1996;83:1112–5.

    Article  PubMed  Google Scholar 

  66. Havenga K, Enker WE, Norstein J, et al. Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients. Eur J Surg Oncol 1999;25:368–74.

    Article  PubMed  Google Scholar 

  67. Heald RJ. Total mesorectal excision: history and anatomy of an operation. In: Odd S, Norstein J, eds. Rectal cancer surgery. Berlin: Springer-Verlag, 1997:203–18.

    Google Scholar 

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Authors and Affiliations

  1. From Sydney Adventist Hospital, Sydney

    Mark Killingback (F.R.A.C.S.) & Prudence Barron M.R.A.

  2. Department of Sociology, Australian National University, Canberra, Australia

    Owen F. Dent Ph.D.

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  1. Mark Killingback
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  2. Prudence Barron M.R.A.
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  3. Owen F. Dent Ph.D.
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Killingback, M., Barron, P. & Dent, O.F. Local recurrence after curative resection of cancer of the rectum without total mesorectal excision. Dis Colon Rectum 44, 473–483 (2001). https://doi.org/10.1007/BF02234317

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