Skip to main content
Log in

Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer

  • 2019 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

High-quality surgery is essential for optimal oncologic outcomes in rectal cancer, but total mesorectal excision (TME) can be difficult for mid- and low rectal cancers. Preoperative identification of patients at risk for difficult TME may change the operative approach. The objective of this study was to determine if MRI pelvimetry can predict poor-quality surgery in patients undergoing laparoscopic low anterior resection (LAR) for mid- and low rectal cancer.

Methods

All patients undergoing laparoscopic LAR for rectal cancer ≤ 9 cm from the anal verge at a single tertiary care referral center from 2011 to 2017 were retrospectively reviewed. Pelvic dimensions were measured from preoperative staging MRI on sagittal and axial views. Pelvimetry variables were all dichotomized based on median values. Exploratory factor analysis then identified the most relevant variables for regression analysis. The primary outcome was poor-quality resection, defined as an incomplete mesorectal grade, or involved circumferential (CRM) or distal (DRM) resection margins.

Results

There were 92 patients included in this study, of which 70% were male, the mean BMI was 26.0 kg/m2, and the mean tumor height was 6.6 cm. Preoperative (chemo)radiotherapy was administered in 70%, and the pathologic T-stage was T3/T4 in 41%. The overall incidence of poor-quality resection was 17%, including 13% incomplete TME, 7% involved CRM, and 1% involved DRM. Factor analysis identified S1-pubic symphysis and the angle between S1 and S5-bottom of symphysis (angle ABD) as relevant variables. After adjusting for pathologic T-stage, BMI, and tumor height, a S1–S5-bottom of symphysis angle > 74.3° (OR 6.19, 95% CI 1.18–32.37) independently predicted poor-quality resection.

Conclusions

MRI pelvimetry can identify patients at risk for a poor-quality resection after laparoscopic proctectomy for mid- and low rectal cancer. These patients may benefit from the selective use of more advanced access methods to improve surgical resection quality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

    Article  CAS  Google Scholar 

  2. Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482

    Article  CAS  Google Scholar 

  3. Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312

    Article  Google Scholar 

  4. Fleshman J, Branda ME, Sargent DJ, Boller AM, George VV, Abbas MA, Peters WR Jr, Maun DC, Chang GJ, Herline A, Fichera A, Mutch MG, Wexner SD, Whiteford MH, Marks J, Birnbaum E, Margolin DA, Larson DW, Marcello PW, Posner MC, Read TE, Monson JRT, Wren SM, Pisters PWT, Nelson H (2019) Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann Surg 269:589–595

    Article  Google Scholar 

  5. Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, O’Callaghan C, Myint AS, Bessell E, Thompson LC, Parmar M, Stephens RJ, Sebag-Montefiore D, Investigators MCN-CCT, Group NCCS (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR1 and NCIC-CTG CO16 randomised clinical trial. Lancet 373:821–828

    Article  Google Scholar 

  6. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, Peters WR Jr, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren SM, Pisters PW, Nelson H (2015) Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314:1346–1355

    Article  CAS  Google Scholar 

  7. Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Davies L, Wilson K, Hague W, Simes J, Investigators AL (2015) Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314:1356–1363

    Article  CAS  Google Scholar 

  8. van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, Bonjer HJ, Group COcLoORIS (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218

    Article  Google Scholar 

  9. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, Heath RM, Brown JM, Group UMCT (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25:3061–3068

    Article  Google Scholar 

  10. Oh SJ, Shin JY (2012) Risk factors of circumferential resection margin involvement in the patients with extraperitoneal rectal cancer. J Korean Surg Soc 82:165–171

    Article  Google Scholar 

  11. Penna M, Cunningham C, Hompes R (2017) Transanal total mesorectal excision: why, when, and how. Clin Colon Rectal Surg 30:339–345

    Article  Google Scholar 

  12. Weaver KL, Grimm LM Jr, Fleshman JW (2015) Changing the way we manage rectal cancer-standardizing tme from open to robotic (including laparoscopic). Clin Colon Rectal Surg 28:28–37

    Article  Google Scholar 

  13. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim DH, Kim JS, Lee HS, Kim JH, Oh JH (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774

    Article  Google Scholar 

  14. Stevenson ARL, Solomon MJ, Brown CSB, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Wilson K, Hague W, Simes J, Australasian Gastro-Intestinal Trials Group Ai (2019) Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the australasian laparoscopic cancer of the rectum randomized clinical trial. Ann Surg 269:596–602

    Article  Google Scholar 

  15. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi PP, Edlin R, Hulme C, Brown J (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318:1569–1580

    Article  Google Scholar 

  16. Rouanet P, Bertrand MM, Jarlier M, Mourregot A, Traore D, Taoum C, de Forges H, Colombo PE (2018) Robotic versus laparoscopic total mesorectal excision for sphincter-saving surgery: results of a single-center series of 400 consecutive patients and perspectives. Ann Surg Oncol 25:3572–3579

    Article  Google Scholar 

  17. Detering R, Roodbeen SX, van Oostendorp SE, Dekker JT, Sietses C, Bemelman WA, Tanis PJ, Hompes R, Tuynman JB, Dutch ColoRectal Cancer Audit G (2019) Three-year nationwide experience with transanal total mesorectal excision for rectal cancer in the netherlands: a propensity score-matched comparison with conventional laparoscopic total mesorectal excision. J Am Coll Surg 228(235–244):e231

    Google Scholar 

  18. Lee L, de Lacy B, Gomez Ruiz M, Liberman AS, Albert MR, Monson JRT, Lacy A, Kim SH, Atallah SB (2018) A multicenter matched comparison of transanal and robotic total mesorectal excision for mid and low-rectal adenocarcinoma. Ann Surg. https://doi.org/10.1097/SLA.0000000000002862

    Article  PubMed  PubMed Central  Google Scholar 

  19. Targarona EM, Balague C, Pernas JC, Martinez C, Berindoague R, Gich I, Trias M (2008) Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 247:642–649

    Article  Google Scholar 

  20. Ogiso S, Yamaguchi T, Hata H, Fukuda M, Ikai I, Yamato T, Sakai Y (2011) Evaluation of factors affecting the difficulty of laparoscopic anterior resection for rectal cancer: “narrow pelvis” is not a contraindication. Surg Endosc 25:1907–1912

    Article  Google Scholar 

  21. Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ (2007) Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 31:1313–1320

    Article  CAS  Google Scholar 

  22. Zhou XC, Su M, Hu KQ, Su YF, Ye YH, Huang CQ, Yu ZL, Li XY, Zhou H, Ni YZ, Jiang YI, Lou Z (2016) CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 11:31–38

    Article  Google Scholar 

  23. Killeen T, Banerjee S, Vijay V, Al-Dabbagh Z, Francis D, Warren S (2010) Magnetic resonance (MR) pelvimetry as a predictor of difficulty in laparoscopic operations for rectal cancer. Surg Endosc 24:2974–2979

    Article  Google Scholar 

  24. Ferko A, Maly O, Orhalmi J, Dolejs J (2016) CT/MRI pelvimetry as a useful tool when selecting patients with rectal cancer for transanal total mesorectal excision. Surg Endosc 30:1164–1171

    Article  Google Scholar 

  25. Zur Hausen G, Grone J, Kaufmann D, Niehues SM, Aschenbrenner K, Stroux A, Hamm B, Kreis ME, Lauscher JC (2017) Influence of pelvic volume on surgical outcome after low anterior resection for rectal cancer. Int J Colorectal Dis 32:1125–1135

    Article  CAS  Google Scholar 

  26. Boyle KM, Petty D, Chalmers AG, Quirke P, Cairns A, Finan PJ, Sagar PM, Burke D (2005) MRI assessment of the bony pelvis may help predict resectability of rectal cancer. Colorectal Dis 7:232–240

    Article  CAS  Google Scholar 

  27. Fernandez Ananin S, Targarona EM, Martinez C, Pernas JC, Hernandez D, Gich I, Sancho FJ, Trias M (2014) Predicting the pathological features of the mesorectum before the laparoscopic approach to rectal cancer. Surg Endosc 28:3458–3466

    Article  Google Scholar 

  28. Battersby NJ, How P, Moran B, Stelzner S, West NP, Branagan G, Strassburg J, Quirke P, Tekkis P, Pedersen BG, Gudgeon M, Heald B, Brown G, Group MIS (2016) Prospective validation of a low rectal cancer magnetic resonance imaging staging system and development of a local recurrence risk stratification model: the MERCURY II Study. Ann Surg 263:751–760

    Article  Google Scholar 

  29. Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, Sebag-Montefiore DJ, Tekkis P, Brown G, Group Ms (2011) Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg 253:711–719

    Article  Google Scholar 

  30. Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, Quirke P, Sebag-Montefiore D, Moran B, Heald R, Guthrie A, Bees N, Swift I, Pennert K, Brown G (2011) Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol 29:3753–3760

    Article  Google Scholar 

  31. Khan MAS, Ang CW, Hakeem AR, Scott N, Saunders RN, Botterill I (2017) The impact of tumour distance from the anal verge on clinical management and outcomes in patients having a curative resection for rectal cancer. J Gastrointest Surg 21:2056–2065

    Article  Google Scholar 

  32. Bonjer HJ, Deijen CL, Haglind E, Group CIS (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 373:194

    PubMed  Google Scholar 

  33. Martinez-Perez A, de’Angelis N (2018) Mid-term results of ACOSOG Z6051 trial sustain the unresolved debate. Ann Surg 270:e52–e53

    Article  Google Scholar 

  34. Pocard M (2017) What quality criterion should we choose to evaluate the surgical resection of rectal cancer? J Visc Surg 154:69–71

    Article  CAS  Google Scholar 

  35. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2008) Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 23:703–707

    Article  Google Scholar 

Download references

Funding

None

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Lawrence Lee.

Ethics declarations

Disclosures

Dr. Liberman has been supported by Servier and Merck for either course work or travel, and serves as on the advisory board for Novadaq and Pfizer. Dr. Lee has an unrestricted education Grant from Johnson & Johnson. Drs. Chau, Charlebois, and Stein, as well as Mr. Soloman have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chau, J., Solomon, J., Liberman, A.S. et al. Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer. Surg Endosc 34, 4609–4615 (2020). https://doi.org/10.1007/s00464-019-07209-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-019-07209-8

Keywords

Navigation