Abstract
Purpose
In patients with low rectal cancer, the intraoperative assessment of sufficient distal resection margins can be challenging. The assessment determines whether reconstruction can be performed or whether permanent colostomy is required. The goal of the present study was to evaluate intraoperative assessment of the total mesorectal excision (TME) specimen during an interruption of the operation.
Methods
The intraoperative strategy of eight patients with low rectal cancer was evaluated. In all cases, intraoperative pathological assessment of the TME specimen by an expert pathologist together with the surgeon was performed. Assessment of the distance of the tumor to the resection margin was measured macroscopically as well as microscopically.
Results
All patients underwent neoadjuvant chemoradiation. The tumor was located at an average 4.8 ± 1.4 cm from the anal verge. In all cases, preoperative MRI revealed mrT3 tumors. The intraoperative assessment showed a median distal resection margin of 10 mm (2–15 mm). In six patients, sufficient margins allowed for reconstruction while in two patients APR was needed. In three patients (37.5%), the pathological assessment changed the operative strategy: In one patient APR could be avoided while two patients required APR instead of the anticipated TME.
Conclusion
The intraoperative assessment of the TME specimen by an expert pathologist together with the surgeon is a valuable tool to avoid unnecessary APR or R1 resections. We therefore suggest routine intraoperative pathological assessment in all operations for borderline low rectal cancers.
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References
Gosens MJ, Klaassen RA, Tan-Go I, Rutten HJ, Martijn H, van den Brule AJ, Nieuwenhuijzen GA, van Krieken JH, Nagtegaal ID (2007) Circumferential margin involvement is the crucial prognostic factor after multimodality treatment in patients with locally advanced rectal carcinoma. Clin Cancer Res 13(22 Pt 1):6617–6623. https://doi.org/10.1158/1078-0432.CCR-07-1197
Williams NS, Dixon MF, Johnston D (1983) Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients' survival. Br J Surg 70(3):150–154
Debove C, Maggiori L, Chau A, Kanso F, Ferron M, Panis Y (2015) What happens after R1 resection in patients undergoing laparoscopic total mesorectal excision for rectal cancer? A study in 333 consecutive patients. Color Dis 17(3):197–204. https://doi.org/10.1111/codi.12849
Gerard JP, Andre T, Bibeau F, Conroy T, Legoux JL, Portier G, Bosset JF, Cadiot G, Bouche O, Bedenne L, Societe Francaise de Chirurgie Digestive SFdEDSFdRO (2017) Rectal cancer: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Dig Liver Dis 49(4):359–367. https://doi.org/10.1016/j.dld.2017.01.152
Monson JR, Weiser MR, Buie WD, Chang GJ, Rafferty JF, Buie WD, Rafferty J, Standards Practice Task Force of the American Society of C, Rectal S (2013) Practice parameters for the management of rectal cancer (revised). Dis Colon rectum 56(5):535–550. https://doi.org/10.1097/DCR.0b013e31828cb66c
Bujko K, Rutkowski A, Chang GJ, Michalski W, Chmielik E, Kusnierz J (2012) Is the 1-cm rule of distal bowel resection margin in rectal cancer based on clinical evidence? A systematic review. Ann Surg Oncol 19(3):801–808. https://doi.org/10.1245/s10434-011-2035-2
Kwak JY, Kim CW, Lim SB, Yu CS, Kim TW, Kim JH, Jang SJ, Kim JC (2012) Oncologically safe distal resection margins in rectal cancer patients treated with chemoradiotherapy. J Gastrointest Surg 16(10):1947–1954. https://doi.org/10.1007/s11605-012-1988-1
Khoury W, Abboud W, Hershkovitz D, Duek SD (2014) Frozen section examination may facilitate reconstructive surgery for mid and low rectal cancer. J Surg Oncol 110(8):997–1001. https://doi.org/10.1002/jso.23758
Gomes RM, Bhandare M, Desouza A, Bal M, Saklani AP (2015) Role of intraoperative frozen section for assessing distal resection margin after anterior resection. Int J Color Dis 30(8):1081–1089. https://doi.org/10.1007/s00384-015-2244-4
Ng CW, Lieske B, Tan KK (2014) Routine histological sampling of doughnuts post oncologic anterior resection is not necessary. Int J Color Dis 29(7):843–845. https://doi.org/10.1007/s00384-014-1886-y
Speake WJ, Abercrombie JF (2003) Should ‘doughnut’ histology be routinely performed following anterior resection for rectal cancer? Ann R Coll Surg Engl 85(1):26–27. https://doi.org/10.1308/003588403321001381
Deen KI, Hubscher S, Bain I, Patel R, Keighley MR (1994) Histological assessment of the distal ‘doughnut’ in patients undergoing stapled restorative proctocolectomy with high or low anal transection. Br J Surg 81(6):900–903
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Rickenbacher, A., Watson, J., Horisberger, K. et al. Direct intraoperative assessment of total mesorectal excision specimens by expert pathologists in patients with very low rectal cancer prevents unnecessary abdominoperineal resections. Int J Colorectal Dis 35, 755–758 (2020). https://doi.org/10.1007/s00384-020-03514-0
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DOI: https://doi.org/10.1007/s00384-020-03514-0