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Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision

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Abstract

Background

Ideal treatment of rectal cancer includes controlling the cancer; minimizing trauma, morbidity, and mortality; and avoiding a colostomy with preservation of adequate function. These goals become more challenging the further distal in the rectum the cancer is located. We sought to determine whether minimally invasive sphincter-preservation surgery (SPS) can accomplish good cancer control, maintaining sphincter function with minimal morbidity and mortality in rectal cancers of the distal 3 cm after receiving neoadjuvant chemoradiotherapy.

Methods

We retrospectively reviewed a prospectively maintained rectal cancer database of a single colorectal surgeon to identify all patients with cancers of the distal 3 cm undergoing SPS via a laparoscopic total mesorectal excision or transanal endoscopic microsurgery (TEM). All patients received neoadjuvant chemoradiotherapy. Patient data, including demographics, initial tumor characteristics, staging, radiation dose, perioperative morbidity and mortality, and local recurrence (LR) and survival, were analyzed.

Results

A total of 161 patients (108 men) underwent SPS via 3 techniques: transanal abdominal transanal proctosigmoidectomy (TATA, n = 106), TEM (n = 49), or ultralow anterior resection (LAR, n = 6). Average age was 62 years (range 22–90 years). The mean levels in rectum from the anorectal ring were as follows: TATA, 1.3 cm (range −1.0 to 3.0 cm), TEM, 1.5 cm (range −0.5 to −3.0 cm), and LAR, 2.9 cm (range 2.5–3.0 cm) (p > 0.05). Preoperative T stage was as follows: T3, n = 108 (TATA 83, TEM 20, LAR 5), T2, n = 48 (TATA 22, TEM 25, LAR 1), T1, n = 3 (TATA 1, TEM 2), and T4, n = 2 (both TEM). All patients received concomitant 5-fluorouracil-based chemotherapy and radiotherapy (mean, 5300 cGy; range 3,000–7,295 cGy). The mean estimated blood loss was 376 ml (range 10–3,600 ml). There were no mortalities. Morbidity rates were as follows: LAR, 0; TATA, 13.2 %; and TEM, 32 % (wound disruption: major, 10 %; minor, 16 %). Pathologic staging was as follows: ypCR: uT2, 34 %, and uT3, 19 %. Overall LR was 3.7 %. By procedure, the follow-up, LR, and KM5YAS, respectively, were: TATA, 37.9 months, 3 and 95 %; TEM, 36.3 months, 6 and 88 %; and LAR, 63.1 months, 0 and 75 % (p > 0.05).

Conclusions

This study demonstrates positive oncologic outcomes, low LR rates, and high KM5YS after minimally invasive SPS. A colostomy-free lifestyle and cancer control make the minimally invasive surgical approach an excellent treatment option for complex distal rectal cancers.

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Disclosures

John Marks, George Nassif, Henry Schoonyoung, Al DeNittis, Eric Zeger, Gerald Marks, and Mo Mohiuddin have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA

    John Marks, George Nassif, Henry Schoonyoung & Gerald Marks

  2. Department of Radiation Oncology, Lankenau Medical Center, Wynnewood, PA, USA

    Al DeNittis & Eric Zeger

  3. King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

    Mohammed Mohiuddin

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  1. John Marks
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Correspondence to John Marks.

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Marks, J., Nassif, G., Schoonyoung, H. et al. Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision. Surg Endosc 27, 4469–4477 (2013). https://doi.org/10.1007/s00464-013-3092-3

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