PURPOSE
This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer.
METHODS
A retrospective chart review was conducted for all patients who underwent curative mesorectal excision for rectal cancer during an eight-year period. Demographic, preoperative, perioperative data were collected. Pelvic sepsis was defined as clinical or radiographically demonstrable leak or a pelvic abscess. Neoadjuvant chemoradiation included 5,040 Gy in conjunction with three cycles of 5-fluorouracil-based chemotherapy, followed by a one-month waiting period.
RESULTS
From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36–97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann’s. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis ≤6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis ≥7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3–9).
CONCLUSIONS
The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients.
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REFERENCES
RJ Heald EM Husband RD Ryall (1982) ArticleTitleThe mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69 613–6 Occurrence Handle6751457
A Wibe B Moller J Norstein et al. (2002) ArticleTitleA national strategic change in treatment policy for rectal cancer—implementation of total mesorectal excision as routine treatment in Norway. A national audit Dis Colon Rectum 45 857–66 Occurrence Handle10.1007/s10350-004-6317-7 Occurrence Handle12130870
RB Arenas A Fichera D Mhoon F Michelassi (1998) ArticleTitleTotal mesenteric excision in the surgical treatment of rectal cancer: a prospective study Arch Surg 133 608–11 Occurrence Handle10.1001/archsurg.133.6.608 Occurrence Handle9637458
RJ Aitken (1996) ArticleTitleMesorectal excision for rectal cancer Br J Surg 83 214–6 Occurrence Handle10.1046/j.1365-2168.1996.02057.x Occurrence Handle8689166
M Murty WE Enker J Martz (2000) ArticleTitleCurrent status of total mesorectal excision and autonomic nerve preservation in rectal cancer Semin Surg Oncol 19 321–8 Occurrence Handle10.1002/ssu.2 Occurrence Handle11241914
AL Martling T Holm LE Rutqvist BJ Moran RJ Heald B Cedemark (2000) ArticleTitleEffect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project Lancet 356 93–6 Occurrence Handle10.1016/S0140-6736(00)02469-7 Occurrence Handle10963244
AF Leong (2003) ArticleTitleTotal mesorectal excision (TME)—twenty years on Ann Acad Med Singapore 32 159–62 Occurrence Handle12772517
A Tocchi G Mazzoni L Lepre et al. (2001) ArticleTitleTotal mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences Arch Surg 136 216–20 Occurrence Handle10.1001/archsurg.136.2.216 Occurrence Handle11177145
WL Law KW Chu (2001) ArticleTitleImpact of total mesorectal excision on the results of surgery of distal rectal cancer Br J Surg 88 1607–12 Occurrence Handle10.1046/j.0007-1323.2001.01929.x Occurrence Handle11736973
E Kapiteijn EK Kranenbarg WH Steup et al. (1999) ArticleTitleTotal mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group Eur J Surg 165 410–20 Occurrence Handle10.1080/110241599750006613 Occurrence Handle10391155
JC Alberts A Parvaiz BJ Moran (2003) ArticleTitlePredicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection Colorectal Dis 5 478–82 Occurrence Handle10.1046/j.1463-1318.2003.00515.x Occurrence Handle12925084
E Rullier C Laurent JL Garrelon P Michel J Saric M Parneix (1998) ArticleTitleRisk factors for anastomotic leakage after resection of rectal cancer Br J Surg 85 355–8 Occurrence Handle10.1046/j.1365-2168.1998.00615.x Occurrence Handle9529492
ND Karanjia AP Corder P Bearn RJ Heald (1994) ArticleTitleLeakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum Br J Surg 81 1224–6 Occurrence Handle7953369
A Vignali VW Fazio IC Lavery et al. (1997) ArticleTitleFactors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients J Am Coll Surg 185 105–13 Occurrence Handle10.1016/S1072-7515(97)00018-5 Occurrence Handle9249076
JR Tuson WG Everett (1990) ArticleTitleA retrospective study of colostomies, leaks and strictures after colorectal anastomosis Int J Colorectal Dis 5 44–8 Occurrence Handle10.1007/BF00496150 Occurrence Handle2313156
K Mealy P Burke J Hyland (1992) ArticleTitleAnterior resection without a defunctioning colostomy: questions of safety Br J Surg 79 305–7 Occurrence Handle1576494
TE Pakkastie PE Luukkonen HJ Jarvinen (1994) ArticleTitleAnastomotic leakage after anterior resection of the rectum Eur J Surg 160 293–7 Occurrence Handle8075199
A Laxamana MJ Solomon Z Cohen SM Feinberg HS Stern RS McLeod (1995) ArticleTitleLong-term results of anterior resection using the double-stapling technique Dis Colon Rectum 38 1246–50 Occurrence Handle10.1007/BF02049147 Occurrence Handle7497834
JE Krook CG Moertel LL Gunderson et al. (1991) ArticleTitleEffective surgical adjuvant therapy for high-risk rectal carcinoma N Engl J Med 324 709–15 Occurrence Handle1997835
Anonymous. Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med 1997;336:980–7
E Kapiteijn CA Marijnen ID Nagtegaal et al. (2001) ArticleTitlePreoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer N Engl J Med 345 638–46 Occurrence Handle11547717
CA Marijnen E Kapiteijn CJ Velde Particlevan de et al. (2002) ArticleTitleAcute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial J Clin Oncol 20 817–25 Occurrence Handle10.1200/JCO.20.3.817 Occurrence Handle11821466
P Friedmann JL Garb DP McCabe et al. (1987) ArticleTitleIntestinal anastomosis after preoperative radiation therapy for carcinoma of the rectum Surg Gynecol Obstet 164 257–60 Occurrence Handle3547721
Anonymous. Randomised trial of surgery alone versus surgery followed by radiotherapy for mobile cancer of the rectum. Medical Research Council Rectal Cancer Working Party. Lancet 1996;348:1610–4
G Valero JA Lujan Q Hernandez et al. (2003) ArticleTitleNeoadjuvant radiation and chemotherapy in rectal cancer does not increase postoperative complications Int J Colorectal Dis 18 495–9 Occurrence Handle10.1007/s00384-003-0520-1 Occurrence Handle14517686
HK Antonsen O Kronborg (1987) ArticleTitleEarly complications after low anterior resection for rectal cancer using the EEA stapling device. A prospective trial Dis Colon Rectum 30 579–83 Occurrence Handle3622160
C Camma M Giunta F Fiorica L Pagliaro A Craxi M Cottone (2000) ArticleTitlePreoperative radiotherapy for resectable rectal cancer: a meta-analysis JAMA 284 1008–15 Occurrence Handle10.1001/jama.284.8.1008 Occurrence Handle10944647
Anonymous. Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet 2001;358:1291–304
AK Chan AO Wong J Langevin et al. (2000) ArticleTitlePreoperative chemotherapy and pelvic radiation for tethered or fixed rectal cancer: a phase II dose escalation study Int J Radiat Oncol Biol Phys 48 843–56 Occurrence Handle10.1016/S0360-3016(00)00692-1 Occurrence Handle11020583
W Graf B Glimelius R Bergstrom L Pahlman (1991) ArticleTitleComplications after double and single stapling in rectal surgery Eur J Surg 157 543–7 Occurrence Handle1683580
R Sauer R Fietkau C Wittekind et al. (2003) ArticleTitleAdjuvant vs. neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94 Colorectal Dis 5 406–15 Occurrence Handle10.1046/j.1463-1318.2003.00509.x Occurrence Handle12925071
LP Fielding S Stewart-Brown R Hittinger L Blesovsky (1984) ArticleTitleCovering stoma for elective anterior resection of the rectum: an outmoded operation? Am J Surg 147 524–30 Occurrence Handle10.1016/0002-9610(84)90016-3 Occurrence Handle6711755
ND Karanjia AP Corder PJ Holdsworth RJ Heald (1991) ArticleTitleRisk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis Br J Surg 78 196–8 Occurrence Handle2015471
R Golub RW Golub R Cantu SuffixJr HD Stein (1997) ArticleTitleA multivariate analysis of factors contributing to leakage of intestinal anastomoses J Am Coll Surg 184 364–72 Occurrence Handle9100681
A Fawcett M Shembekar JS Church R Vashisht RG Springall DM Nott (1996) ArticleTitleSmoking, hypertension, and colonic anastomotic healing; a combined clinical and histopathological study Gut 38 714–8 Occurrence Handle8707117
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Buie, W., MacLean, A., Attard, JA. et al. Neoadjuvant Chemoradiation Increases the Risk of Pelvic Sepsis After Radical Excision of Rectal Cancer. Dis Colon Rectum 48, 1868–1874 (2005). https://doi.org/10.1007/s10350-005-0154-1
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DOI: https://doi.org/10.1007/s10350-005-0154-1