Abstract
Purpose
Rectal washout is performed in rectal cancer surgery to eliminate exfoliated cancer cells. Before rectal washout, a cross-clamp should generally be placed distal to the tumor. In some patients with lower rectal cancer, however, the tumor cannot be adequately isolated. We, therefore, hypothesized that neoadjuvant chemoradiotherapy (nCRT) can decrease the number of exfoliated cancer cells even after the rectal washout including tumors.
Methods
We prospectively studied 86 patients with rectal cancer who underwent proctectomy after nCRT. A cross-clamp was applied proximal to the tumor, and the rectum was washed with 2000 mL of physiological saline solution. The initial 100 mL used to wash the rectum was collected as a pre-washout sample. After the rectum was washed with the remaining 1900 mL, the solution remaining in the rectum was collected as a post-washout sample. Cells classified as class IV or higher according to the papanicolaou classification were considered to indicate a positive diagnosis.
Results
The cytological diagnosis was positive in pre-washout samples in 21 patients (24%) and post-washout samples in two patients (2%).
Conclusion
In patients with rectal cancer, nCRT may decrease the number of exfoliated cancer cells in the rectum, and rectal washout including the tumor may be oncologically acceptable.
Similar content being viewed by others
References
Umpleby HC, Fermor B, Symes MO, Williamson RC. Viability of exfoliated colorectal carcinoma cells. Br J Surg. 1984;71:659–63.
McGregor JR, Galloway DJ, McCulloch P, George WD. Anastomotic suture materials and implantation metastasis: an experimental study. Br J Surg. 1989;76:331–4.
Gertsch P, Baer HU, Kraft R, Maddern GJ, Altermatt HJ. Malignant cells are collected on circular staplers. Dis Colon Rectum. 1992;35:238–41.
Hubens G, Lafullarde T, Van Marck E, Vermeulen P, Hubens A. Implantation of colon cancer cells on intact and damaged colon mucosa and serosa: an experimental study in the rat. Acta Chir Belg. 1994;94:258–62.
Sayfan J, Averbuch F, Koltun L, Benyamin N. Effect of rectal stump washout on the presence of free malignant cells in the rectum during anterior resection for rectal cancer. Dis Colon Rectum. 2000;43:1710–2.
Maeda K, Maruta M, Hanai T, Sato H, Horibe Y. Irrigation volume determines the efficacy of “rectal washout”. Dis Colon Rectum. 2004;47:1706–10.
Xingmao Z, Jianjun B, Zheng W, Jianwei L, Junjie H, Zhixiang Z. Analysis of outcomes of intra-operative rectal washout in patients with rectal cancer during anterior resection. Med Oncol. 2013;30:386.
Simillis C, Mistry K, Prabhudesai A. Intraoperative rectal washout in rectal cancer surgery: a survey of current practice in the UK. Int J Surg. 2013;11:993–7.
Umpleby HC, Williamson RC. The efficacy of agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann Royal Coll Surg Engl. 1984;66:192–4.
Augestad KM, Lindsetmo RO, Reynolds H, Stulberg J, Senagore A, Champagne B, et al. International trends in surgical treatment of rectal cancer. Am J Surg. 2011;201:353–7.
Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.
Gerard JP, Conroy T, Bonnetain F, Bouche O, Chapet O, Closon-Dejardin MT, et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol. 2006;24:4620–5.
Rondelli F, Trastulli S, Cirocchi R, Avenia N, Mariani E, Sciannameo F, et al. Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis. Colorectal Dis. 2012;14:1313–21.
Matsuda A, Kishi T, Musso G, Matsutani T, Yokoi K, Wang P, et al. The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis. Ann Surg Oncol. 2013;20:856–63.
Zhou C, Ren Y, Li J, Li X, He J, Liu P. Systematic review and meta-analysis of rectal washout on risk of local recurrence for cancer. J Surg Res. 2014;189:7–16.
Okoshi K, Kono E, Tomizawa Y, Kinoshita K. Can rectal washout reduce anastomotic recurrence after anterior resection for rectal cancer? A review of the literature. Surg Today. 2019. https://doi.org/10.1007/s00595-019-01825-6.
Terzi C, Unek T, Sagol O, Yilmaz T, Fuzun M, Sokmen S, et al. Is rectal washout necessary in anterior resection for rectal cancer? A prospective clinical study. World J Surg. 2006;30:233–41.
Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K, et al. ESMO consensus guidelines for management of patients with colon and rectal cancer. A personalized approach to clinical decision making. Ann Oncol. 2012;23:2479–516.
Sadahiro S, Suzuki T, Tanaka A, Okada K, Kamijo A, Murayama C, et al. Phase I/II study of preoperative concurrent chemoradiotherapy with S-1 for locally advanced, resectable rectal adenocarcinoma. Oncology. 2011;81:306–11.
Suzuki T, Sadahiro S, Tanaka A, Okada K, Kamata H, Kamijo A, et al. Biopsy specimens obtained 7 days after starting chemoradiotherapy (CRT) provide reliable predictors of response to CRT for rectal cancer. Int J Radiat Oncol Biol Phys. 2013;85:1232–8.
Han KS, Sohn DK, Kim DY, Kim BC, Hong CW, Chang HJ, et al. Endoscopic criteria for evaluating tumor stage after preoperative chemoradiation therapy in locally advanced rectal cancer. Cancer Res Treat. 2016;48:567–73.
Sohn DK, Han KS, Kim BC, Hong CW, Chang HJ, Baek JY, et al. Endoscopic assessment of tumor regression after preoperative chemoradiotherapy as a prognostic marker in locally advanced rectal cancer. Surg Oncol. 2017;26:453–9.
Sadahiro S, Suzuki T, Tanaka A, Okada K, Kamata H, Ozaki T, et al. Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial. Surgery. 2014;155:493–503.
Vernava AM 3rd, Moran M, Rothenberger DA, Wong WD. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet. 1992;175:333–6.
Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer. 1995;76:388–92.
Koss LG. Diagnostic cytology and its histopathologic bases. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 1992. p. 1429–31.
Dafnis G, Nordstrom M. Evaluation of the presence of intraluminal cancer cells following rectal washout in rectal cancer surgery. Tech Coloproctol. 2013;17:363–9.
Latkauskas T, Pauzas H, Gineikiene I, Janciauskiene R, Juozaityte E, Saladzinskas Z, et al. Initial results of a randomized controlled trial comparing clinical and pathological downstaging of rectal cancer after preoperative short-course radiotherapy or long-term chemoradiotherapy, both with delayed surgery. Colorectal Dis. 2012;14:294–8.
Constantinides VA, Cheetham D, Nicholls RJ, Tekkis PP. Is rectal washout effective for preventing localized recurrence after anterior resection for rectal cancer? Dis Colon Rectum. 2008;51:1339–44.
Edwards DP, Sexton R, Heald RJ, Moran BJ. Long-term results show triple stapling facilitates safe low colorectal and coloanal anastomosis and is associated with low rates of local recurrence after anterior resection for rectal cancer. Tech Coloproctol. 2007;11:17–21.
Glaysher MA, Moore T, Miles AJ. Rectal sling technique to assist rectal washout during laparoscopic anterior resection for colorectal cancer. Ann Royal Coll Surg Engl. 2013;95:531.
Rondelli F, Santinelli R, Stella P, Bugiantella W, Ceccarelli G, Balzarotti RC, et al. A new surgical device for anterograde intraoperative rectal washout. Surg Innov. 2018;25:203–7.
Funding
There was no funding source for this study.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest.
Ethical approval
Ethical approval from the institutional review board of Tokai University was obtained. All patients provided their written informed consent before participation.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Okada, K., Sadahiro, S., Kamei, Y. et al. A prospective clinical study assessing the presence of exfoliated cancer cells and rectal washout including tumors in patients who receive neoadjuvant chemoradiotherapy for rectal cancer. Surg Today 50, 352–359 (2020). https://doi.org/10.1007/s00595-019-01883-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00595-019-01883-w