Low preoperative maximum squeezing pressure evaluated by anorectal manometry is a risk factor for non-reversal of diverting stoma.

PURPOSE: A diverting stoma is created to prevent anastomotic leakage and related complications impairing sphincteric function in rectal surgery. However, diverting stoma may be left unclosed. This study is aimed to analyze preoperative factors including anorectal manometric data associated with diverting stoma non-reversal before rectal surgery. We also addressed complications related to diverting stoma in patients undergoing surgery for rectal malignant tumor. METHODS: A total of 203 patients with rectal malignant tumor who underwent sphincter-preserving surgery with diverting stoma were retrospectively evaluated. The risk factors for non-reversal of diverting stoma were identified by univariate and multivariate analyses. For these analyses, anorectal manometric data were measured before rectal surgery. The association between stoma-related complications and other clinicopathological features was also analyzed. RESULTS: During the median follow-up of 46.4 months, 24% (49 patients) did not undergo stoma reversal. Among parameters that were available before rectal surgery, age ≥ 75 years, albumin < 3.5 g/dl, tumor size ≥ 30 mm, tumor distance from the anal verge < 4 cm, and maximum squeezing pressure (MSP) < 130 mmHg measured by anorectal manometry (ARM) were independent factors associated with stoma non-reversal. The most common stoma-related complication was peristomal skin irritation (25%). Ileostomy was the only factor associated with peristomal skin irritation. CONCLUSION: The current study demonstrated that low preoperative MSP evaluated by ARM, old age, hypoalbuminemia, and a large tumor close to the anus were predictive of diverting stoma non-reversal. Stoma site should be well deliberated when patients have the aforementioned risk factors for diverting stoma non-reversal.

The Influence of Neoadjuvant Chemoradiation for Middle and Lower Rectal Cancer on Anorectal Function.

BACKGROUND/AIM: To date, there is no clear understanding whether preoperative long-course chemoradiotherapy combined with surgery for rectal cancer is detrimental to anorectal function. The purpose of this study was to clarify the influence of preoperative chemoradiotherapy and surgery for middle and lower rectal cancer on postoperative anorectal function. PATIENTS AND METHODS: Data of 113 patients with middle or lower rectal cancer treated with preoperative chemoradiotherapy plus surgery or surgery alone between January 2013 and December 2016 were analyzed. A total of 84 and 29 patients underwent low anterior resection and intersphincteric resection, respectively. In patients with T3 or deeper and with any N stage cancer below peritoneal reflection, surgery plus lateral lymph node dissection or preoperative radiation (total: 50.4 Gy/28 fractions) to the pelvis with chemoradiotherapy plus surgery was treated. Anorectal function was assessed prior to treatment and 6 and 12 months postoperatively. Specifically, maximum resting pressure and maximum squeezing pressures were measured. The Wexner score was recorded prior to treatment and 12 months postoperatively. RESULTS: maximum resting pressure and maximum squeezing pressure decreased post-surgery in both groups. Maximum resting pressure and maximum squeezing pressure at 12 months and the Wexner score at 12 months post-surgery were comparable among patients treated with chemoradiotherapy plus surgery and those treated with surgery alone. CONCLUSION: Preoperative chemoradiotherapy did not clearly impair postoperative anorectal function in patients who underwent low anterior resection and intersphincteric resection.

The influence of neoadjuvant chemoradiation for lower rectal cancer on urinary function.

BACKGROUND: It is unclear whether neoadjuvant chemoradiation for lower rectal cancer causes a deterioration in urinary function. This study aimed to prospectively compare the postoperative urinary function of patients with lower rectal cancer treated by surgery after neoadjuvant chemoradiation with that of patients treated with surgery alone. METHOD: Urinary function was assessed before treatment and 1, 3, and 6 months after surgery by calculating the changes in the scores of the seven items of the International Prostatic Symptom Score (incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia) and Quality of life index. RESULTS: Among 123 patients with lower rectal cancer treated with chemoradiotherapy plus surgery and surgery alone between 2014 and 2016, 29 eligible patients in the surgery after neoadjuvant chemoradiation group and 34 eligible patients in the surgery alone group were analyzed. The changes in each item score at 1, 3, and 6 months after surgery were similar between the two treatment groups. The scores of all items were already recovered at 6 months after surgery, except for weak stream and straining in the Surgery + chemoradiotherapy group and nocturia in the Surgery-alone group. CONCLUSION: Neoadjuvant chemoradiotherapy for lower rectal cancer did not affect postoperative urinary function.

Over-diagnosis for preoperative T staging of colorectal cancer - A case series.

INTRODUCTION: Recent progressive imaging technology such as multiplanar reconstruction on computed tomography (CT) and colonoscopy has made preoperative T staging of colorectal cancer (CRC) more accurate. Nevertheless, it is still difficult to make a correct diagnosis in some cases. The aim of this case study was to investigate the accuracy of T staging diagnosis in patients with CRC who underwent curative operations and to identify the causes of preoperative over-diagnosis. METHOD: Medical charts of 1013 colorectal cancer patients who underwent a curative operation in the University of Tokyo Hospital between January 2011 and December 2016 were analyzed retrospectively. We defined a two-level or more difference between clinical and pathological T stages as over-diagnosis or under-diagnosis. RESULTS: Nine patients were over-diagnosed in T stage preoperatively. The rate of over-diagnosis was 0.9%. At least three main factors for over-diagnosis were identified: close-to-circumferential or obstructive lesion; a rough appearance in the adipose tissues around the tumor on CT; and a tumor with a depressed structure. CONCLUSIONS: Clinical T stage is overestimated with a marked difference from pathological T stage in approximately 1% of CRC patients. Further progress in diagnostic modalities is required for more accurate staging.