Survival outcome of adjuvant radiotherapy after local excision for T2 early rectal cancer: An analysis based on the surveillance, epidemiology, and end result registry database.

BACKGROUND: Major resection (MR) is recommended for cases with T2 finding after local excision (LE) of early rectal cancer, but the revision procedure is accompanied with high morbidity. We evaluated the oncological safety of LE followed by adjuvant radiotherapy as a rectum-preserving alternative to MR for T2 early rectal cancer. METHODS: A total of 3786 patients with T2N0M0 rectal adenocarcinoma between 1998 and 2013 were included from the SEER database. Survival rates were compared using the Kaplan-Meier method with a log-rank test, and multivariate analyses were performed using Cox proportional regression models. RESULTS: Of these patients included, 429 (11.3%) treated with LE alone (LE group), 3067 (81.0%) treated with MR (MR group), and 290 (7.7%) treated with LE followed by adjuvant radiotherapy (LE + adjuvant RT group). The 5-year cancer specific survival (CSS) rate and 5-year overall survival (OS) rate were significantly lower in LE patients group than those in MR patients group (70.5% vs. 81.8%, P < 0.001; 57.3% vs. 72.3%, P < 0.001). The 5-year CSS rate and 5-year OS rate were similar between LE + adjuvant RT and MR groups (78.4% vs. 81.8%, P = 0.975, and 70.7% vs. 72.3%, P = 0.311, respectively). Multivariate Cox regression revealed that treatment strategies, age and CEA status were independently associated with CSS and OS. After age adjustment, LE was associated with reduced CSS (using MR as a reference, HR, 1.784; P < 0.001) and reduced OS (HR, 1.739; P < 0.001). However, CSS and OS related to LE + adjuvant RT of T2 rectal cancer group weren't be affected (HR, 0.994; P = 0.962 and HR, 0.904; P = 0.302, respectively). CONCLUSIONS: When MR is inappropriate for T2 early rectal cancer patients because of patients refusal or co-morbidities, LE + adjuvant RT can provide acceptable levels of long-term survival.

Risk Factors for Early Postoperative Small Bowel Obstruction after Elective Colon Cancer Surgery: An Observational Study of 1,244 Consecutive Patients.

BACKGROUND: Early postoperative small bowel obstruction (EPSBO) is a common complication following colon cancer surgery. EPSBO is associated with increased hospital stays, mortality rates, and healthcare costs. The purpose of this study was to identify risk factors for EPSBO following elective colon cancer surgery. STUDY DESIGN: We retrospectively reviewed the clinicopathological variables of 1,244 patients with colon cancer who underwent partial colectomy from January 2000 to December 2014. A multivariable logistic regression model was used to identify risk factors for EPSBO. RESULTS: The EPSBO rate was 3.5%. In multivariate analysis, preoperative bowel obstruction (OR 2.378; 95% CI 0.986-5.735, p = 0.054), weight loss >10% of body weight (OR 3.029; 95% CI 1.000-9.178, p = 0.05), albumin level (in g/L; OR 0.966; 95% CI 0.937-0.996, p = 0.024), and surgical duration (in min; OR 1.008; 95% CI 1.003-1.012, p = 0.003) were significant predictors of EPSBO. CONCLUSION: EPSBO is more likely to develop in the presence of poor systemic conditions (e.g., weight loss >10% of body weight, hypoalbuminemia, and preoperative bowel obstruction) and following operations of longer duration. These predictors may facilitate the stratification of patients at risk for EPSBO following surgery for elective colon cancer.

Effect of Neoadjuvant Chemoradiotherapy on Locally Advanced Rectal Mucinous Adenocarcinoma: A Propensity Score-Matched Study.

Aims. To compare the surgical and oncological outcomes of rectal mucinous adenocarcinomas treated with neoadjuvant chemoradiotherapy versus surgery alone. Methods. A total of 167 locally advanced rectal mucinous adenocarcinoma patients treated with neoadjuvant chemoradiotherapy and surgery alone between 2008 and 2014 were matched using propensity score; the surgical and oncological outcomes were compared. Results. Ninety-six patients were matched. Postoperative morbidity was similar between groups. Sphincter preservation rate was higher in patients receiving neoadjuvant chemoradiotherapy (79.2% versus 60.4%, P = 0.045), especially for tumors ≥ 3 cm but ≤5 cm from the anal verge (75.0% versus 44.0%, P = 0.036). With a median follow-up of 54.8 months, the 5-year overall survival rate (neoadjuvant chemoradiotherapy versus surgery alone: 79.6% versus 67.1%; P = 0.599) and disease-free survival rate (75.6% versus 64.2%; P = 0.888) were similar. The 5-year local recurrence rate was lower in patients receiving neoadjuvant chemoradiotherapy (7.7% versus 26.0%, P = 0.036), while no difference was observed in distant metastasis. A poor response to chemoradiation was associated with higher local recurrence (P = 0.037). Conclusions. Compared with surgery alone, neoadjuvant chemoradiotherapy was found to increase the sphincter preservation rate and reduce local recurrence, thus being beneficial for locally advanced rectal mucinous adenocarcinoma patients.

A scoring system basing pathological parameters to predict regional lymph node metastasis after preoperative chemoradiotherapy for locally advanced rectal cancer: implication for local excision.

Local excision is an alternative to radical surgery that is indicated in patients with locally advanced rectal cancer (LARC) who have a good response to chemoradiotherapy (CRT). Regional lymph node status is a major uncertainty during local excision of LARC following CRT. We retrospectively reviewed clinicopathologic variables for 244 patients with LARC who were treated at our institute between December 2000 and December 2013 in order to identify independent predictors of regional lymph node metastasis. Multivariate analysis of the training sample demonstrated that histopathologic type, tumor size, and the presence of lymphovascular invasion were significant predictors of regional nodal metastasis. These variables were then incorporated into a scoring system in which the total scores were calculated based on the points assigned for each parameter. The area under the curve in the receiver operating characteristic analysis was 0.750, and the cutoff value for the total score to predict regional nodal metastasis was 7.5. The sensitivity of our system was 73.2% and the specificity was 69.4%. The sensitivity was 77.8% and the specificity was 51.2% when the scoring system was applied to the testing sample. Using this system, we could accurately predict regional nodal metastases in LARC patients following CRT, which may be useful for stratifying patients in clinical trials and selecting potential candidates for organ-sparing surgery following CRT for LARC.

Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome.

BACKGROUND: Traditionally, conventional intersphincteric resection requires a combined abdominal and perineal approach and a handsewn coloanal anastomosis procedure, which is difficult to accomplish via the perineal approach. A completely abdominal approach partial intersphincteric resection (APISR) with laparoscopy can simplify the anastomosis procedure. This study evaluated the intermediate-term oncological and functional results of laparoscopic versus open APISR for low rectal cancer. METHODS: A total of 137 consecutive patients with low rectal cancer who underwent APISR from January 2006 to August 2013 were retrospectively evaluated. Patient groups were classified into as open surgery (OP, n = 48) group and laparoscopy (LAP, n = 89). The primary endpoint was 3-year disease-free survival and the Wexner score for anal function. RESULTS: The LAP group had longer operating time, less intraoperative blood loss, and shorter hospital stay after surgery compared with the OP group. Median follow-up was 32.3 months. The local recurrence rates were similar in the two groups (LAP 3.2% vs. OP 6.1%; P = 0.652). The combined 3-year disease-free survival rate was 83.2% in the LAP group and 83.8% in the OP group (P = 0.857). Wexner scores were similar in the two groups (LAP 2.9 ± 4.5 vs. OP 3.1 ± 5.0). In the LAP group, 89.7% of patients had good continence compared with 91.4% in the OP group (P = 0.311). CONCLUSIONS: Laparoscopic APISR can be performed safely and offers similar intermediate-term oncological and functional outcome compared with the open procedure. The oncological adequacy requires long-term follow-up data.

A scoring system to predict inferior mesenteric artery lymph node metastasis and prognostic value of its involvement in rectal cancer.

PURPOSE: The aim of this study is to establish a prediction scoring system for inferior mesenteric artery (IMA) lymph node metastasis and to assess the prognostic impact of dissection of positive IMA node on patients with stage III rectal cancer. METHODS: A retrospective study was performed in 264 patients with stage III rectal cancer undergoing curative surgery. Clinicopathological, survival, and recurrence data were compared between 29 patients with positive IMA nodes and 235 patients with negative IMA nodes. Clinicopathological data which were found to be significantly associated with IMA nodal status were incorporated into a scoring system. RESULTS: In the training samples, tumor differentiation and preoperative serum CEA were significant predictors of IMA node metastasis in multivariate analysis, which were incorporated into a scoring system. Using receiver operating characteristic curve analysis, we determined a cutoff value of 46.5 for scores, at which the system's sensitivity was 86 % and specificity 61 %. When applied to testing sample, the sensitivity was 80 % and specificity 60 %. Survival analysis showed that 5-year disease-free survival rate (5-DFS) and 5-year overall survival (5-OS) in the positive IMA node group (24.4 and 27.6 %, respectively) were significantly lower than in the negative IMA node group (61.8 and 71.3 %, respectively) (P < 0.001). Furthermore, multivariate analysis indicated that IMA lymph node metastasis was an unfavorable independent prognostic factor for 5-DFS and 5-OS. CONCLUSIONS: IMA lymph node metastasis is an independent poor prognostic factor for stage III rectal cancer. The prediction scoring system for IMA node metastasis would be beneficial in determining the appropriate level of IMA ligation.

[Risk factors of postoperative chyle leak following complete mesocolic excision for colon cancer].

OBJECTIVE: To investigate the incidence, risk factors and preventative methods associated with chyle leak following complete mesocolic excision(CME) for colon cancer. METHODS: Clinical data of 592 patients with colon cancer undergoing CME in the department of Colorectal Surgery in the Fujian Medical University Union Hospital from September 2000 to September 2011 were analyzed retrospectively. RESULTS: Chyle leak occurred in 46 patients(7.7%). The incidence of postoperative chyle leak following right CME hemicolectomy was 13.3%(30/226), significantly higher than that after left CME hemicolectomy (4.4%). On univariate analysis, chyle leak following CME was associated with tumor size(P<0.05), tumor location(P<0.01), and lymph nodes harvested(P<0.01). Multivariate logistic regression revealed that tumor location and lymph nodes harvested were independent risk factors associated with chyle leak following CME(P<0.05). CONCLUSIONS: Tumor location and lymph nodes harvested are independent risk factors for chyle leak following complete mesocolic excision for colon cancer. When the drainage output suddenly increases after oral intake resumption, the chyle test of ascitic fluid should be performed for early diagnosis and prompt management.

[Comparison of efficacy between laparoscopic versus open complete mesocolic excision for colon cancer].

OBJECTIVE: To explore the differences in long-term outcomes between laparoscopic and open complete mesocolic excision(CME) for colon cancer. METHODS: A total of 273 patients with colon cancer who underwent CME at the Fujian Medical University Union Hospital from September 2000 to December 2008 were divided into laparoscopic(LP, n=147) and open(OP, n=126) groups in a non-random manner. The oncologic and long-term outcomes were compared. RESULTS: No significant differences were seen in the length of distal and proximal margin, and number of lymph nodes(all P>0.05). Median postoperative follow up was 50 months. Local regional recurrence rates (LP 6.1% vs. OP 7.9%) and distal metastasis rates(LP 23.8% vs. OP 16.7%) were similar between the two groups(all P>0.05). The 5-year overall survival rates (LP 69.4% vs. OP 74.0%, P=0.840) and 5-year disease-free survival rates(LP 68.5% vs. OP 70.9%, P=0.668) between the two groups were not statistically different. CONCLUSIONS: Laparoscopic CME has the same oncologic clearance effects compared with open CME for colon cancer. It might become a new standardized surgery for colon cancer.

[Comparing the influencing factors of anastomotic bleeding in rectal carcinoma resection between laparoscopic and open radical approaches].

OBJECTIVE: To observe the occurrence of anastomotic bleeding following laparoscopic and open radical resection for rectal carcinoma, and to explore its contributing factors. METHODS: Two hundred and sixty-three cases of rectal carcinoma undergone radical resection were divided into 2 groups, laparoscopic surgery (LS) group (n=86) and open surgery (OS) group (n=177). According to the different locations of anastomotic stoma and with or without preventive colostomy, the two groups were divided into AR sub-group and LAR/UAR sub-group, colostomy sub-group and non-colostomy sub-group. After analyzing the incidence of anastomotic bleeding in each sub-group, a logistic regression model was established to determine the relationships between anastomotic bleeding and three contributing factors including surgical approaches (LS or OS), location of stoma (AR or LAR/UAR) and preventive colostomy. RESULTS: Anastomotic bleeding occurred on 16 out of 263 patients with radical resection of rectal cancer (6.1%). The rates of anastomotic bleeding in LS group and OS group were 9.3% and 4.5%, in colostomy and non-colostomy were 8.1% and 5.5%, and in AR group and LAR/UAR group were 3.3% and 12.1% respectively, there were no significant differences between them (P>0.05). Comparing the two different surgical approaches (LS vs OS), the coefficient of regression, odd ratio and standard coefficient of regression for LS were 1.319, 3.741 and 0.342 respectively. In comparison of the locations of anastomosis (AR vs LAR/UAR), the three index for LAR/UAR were 2.460, 11.704, and 0.632 respectively. Comparing colostomy with non-colostomy, the three index for colostomy were -1.394, 0.248, and -0.327 respectively. CONCLUSIONS: Anastomotic bleeding after radical rectectomy is related to the choice of surgical approach, location of anastomosis and with or without preventive colostomy. Both LS and LAR/UAR are risk factors, and preventive colostomy is a protective factor. Regarding to the significance of three factors, location of anastomosis takes the first place, following by surgical method and with or without preventive colostomy.

[Comparison of surgical complication rate between laparoscopic and open radical resection for colorectal cancer].

OBJECTIVE: To compare the surgical complication rate between laparoscopic and open radical resection for colorectal cancer. METHODS: From September 2000 to December 2005, 491 cases with colorectal cancer were divided into two groups prospectively and nonrandomly,and received radical laparoscopic operation (LP, n=214) and open operation (OP, n=277). The intra- and post-operative complication rate were compared between the two groups. RESULTS: In laparoscopic groups, 14 cases (6.54%,14/214) were converted to open surgery,because of intra-operative complications in 7 cases,obesity or large tumors in 5 cases,narrow- pelvis in one case and retroperitoneal tumor in one case. The intra-operative complication rate was 4.8% (10/207) in LP group and 3.6% (10/277) in OP group (P > 0.05, chi2=0.446). There were no differences in post- operative intestinal obstruction, stoma leak, stoma bleeding, chyle leak, pulmonary infection except incision infection(5.5% vs 14.1%, P< 0.05) between LP and OP groups. The overall postoperative complication rate was 23.5% (47/200) in LP group and 36.8% (102/277) in OP group (P< 0.01, chi2=9.598). CONCLUSIONS: There is no difference in intra-operative complication rate between LP and OP groups,but the post-operative complication rate is significantly lower in LP group than that in OP group.