Update on Minimally Invasive Surgical Approaches for Rectal Cancer.

PURPOSE OF REVIEW: This review aims to clarify the current role of minimally invasive surgery in the treatment of rectal cancer, highlighting short- and long-term outcomes from the latest trials and studies. RECENT FINDINGS: Data from previous trials has been conflicting, with some failing to demonstrate non-inferiority of laparoscopic surgical resection of rectal cancer compared to an open approach and others demonstrating similar clinical outcomes. Robot-assisted surgery was thought to be a promising solution to the challenges faced by laparoscopic surgery, and even though the only randomized controlled trial to date comparing these two techniques did not show superiority of robot-assisted surgery over laparoscopy, more recent retrospective data suggests a statistically significant higher negative circumferential resection margin rate, decreased frequency of conversion to open, and less sexual and urinary complications. Minimally invasive surgery techniques for resection of rectal cancer, particularly robot-assisted, offer clear short-term peri-operative benefits over an open approach; however, current data has yet to display non-inferiority in terms of oncological outcomes.

Validation study of the ACS NSQIP surgical risk calculator for two procedures in Japan.

INTRODUCTION: The ACS NSQIP Surgical Risk Calculator (SRC) assesses risk to support goal-concordant care. While it accurately predicts US outcomes, its performance internationally is unknown. This study evaluates SRC accuracy in predicting mortality following low anterior resection (LAR) and pancreaticoduodenectomy (PD) in NSQIP patients and accuracy retention when applied to native Japanese patients (National Clinical Database, NCD). METHODS: NSQIP (41,260 LAR; 15,114 PD) and NCD cases (61,220 LAR; 27,901 PD) from 2015 to 2017 were processed through the SRC mortality model. Country-specific calibration and discrimination were assessed with and without an intercept correction applied to the Japanese data. RESULTS: The SRC exhibited acceptable calibration for LAR and PD when applied to NSQIP data but miscalibration for NCD data. A simple correction to the model intercept, motivated by lower mortality rates in the Japanese data, successfully remediated the miscalibration. CONCLUSIONS: The SRC may inaccurately predict surgical risk when applied to the native Japanese population. An intercept correction method is suggested when miscalibration is encountered; it is simple to implement and may permit effective international use of the SRC.

Comparing outcomes for non-metastatic rectal cancer in academic vs. community centers: A propensity-matched analysis of the National Cancer Database.

BACKGROUND: Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions. METHODS: The National Cancer Database (2010-2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression. RESULTS: After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen. CONCLUSIONS: No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume.

Size Criteria Is Not Sufficient in Selecting Patients for Local Excision Versus Radical Excision for Rectal Neuroendocrine Tumors >2 cm: A National Cancer Database Analysis.

BACKGROUND: Patients with rectal neuroendocrine tumors >2 cm often undergo radical surgery, despite limited data supporting this practice. Five- and 10-year survival rates for these patients have been reported previously as 74.8% and 58.6%. OBJECTIVE: Overall survival was compared between local excision and radical surgery and pN0 and pN1 within the radical surgery subgroup for rectal neuroendocrine tumors >2 cm. Factors independently associated with survival were identified. DESIGN: A retrospective, nationwide, multivariate regression analysis was performed. SETTINGS: Data are from the National Cancer Database (2004-2013). PATIENTS: Patients with rectal neuroendocrine tumors >2 cm, excluding stages T4 and M1, were included. MAIN OUTCOME MEASURES: Outcome measures were overall survival and independent risk factors for overall survival based on multivariate regression analysis. RESULTS: Each group had 178 patients. After local excision, 5- and 10-year overall survival rates were 88% and 72% vs 51% and 42% after radical surgery (p < 0.001). A multivariate Cox proportional hazards model showed similar survival (p = 0.96). Tumor factors independently associated with survival were nodal metastasis (HR = 2.01 (95% CI, 1.01-3.97)), poorly differentiated tumors (HR = 4.82 (95% CI, 1.65-14.01)), and undifferentiated tumors (HR = 9.91 (95% CI, 2.77-35.49)). After radical surgery, patients with and without nodal metastasis had 5-year survival rates of 44% vs 59% (unadjusted p = 0.09; adjusted p = 0.11), with insufficient 10-year survival data. LIMITATIONS: The study is a retrospective analysis and includes only Commission on Cancer-accredited hospitals. Long-term follow-up was limited. Lymphovascular invasion was missing for a majority of patients analyzed. CONCLUSIONS: Local excision for select patients with rectal neuroendocrine tumors >2 cm is a viable alternative to radical surgery. Nodal status and tumor grade independently predict survival and should be factored into surgical intervention selection. In higher-risk patients selected for radical surgery, survival was similar between the pN0 and pN1 groups, possibly indicating a benefit of radical surgery for these patients. See Video Abstract at http://links.lww.com/DCR/B455. EL CRITERIO DE TAMAO NO ES SUFICIENTE PARA SELECCIONAR PACIENTES PARA LA ESCISIN LOCAL VERSUS ESCISIN RADICAL PARA TUMORES NEUROENDOCRINOS RECTALES CM ANLISIS DE UNA BASE DE DATOS NACIONAL DE CANCER: ANTECEDENTES:Los pacientes con tumores neuroendocrinos rectales >2 cm a menudo se someten a cirugía radical, a pesar de los datos limitados que respaldan esta práctica. La supervivencia a cinco y diez años para estos pacientes se había informado anteriormente como 74,8% y 58,6%, respectivamente.OBJETIVO:Se comparó la supervivencia global entre escisión local y cirugía radical, y pN0 y pN1 dentro del subgrupo de cirugía radical para tumores neuroendocrinos rectales >2 cm. Se identificaron factores asociados de forma independiente con la supervivencia.DISEÑO:Se realizó un análisis retrospectivo de regresión multivariante a nivel nacional.AJUSTE:Los datos provienen de la Base de Datos Nacional sobre el cáncer (2004-2013).PACIENTES:Pacientes con tumores neuroendocrinos rectales > 2 cm, excluyendo los estadios T4 y M1.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado fueron la supervivencia general y los factores de riesgo independientes para la supervivencia general según el análisis de regresión multivariante.RESULTADOS:Cada grupo tuvo 178 pacientes. Después de la escisión local, la supervivencia global a cinco y diez años fue del 88% y 72% frente al 51% y el 42% después de la cirugía radical (p <0,001). Un modelo multivariado de riesgos proporcionales de Cox mostró una supervivencia similar (p = 0,96). Los factores tumorales asociados de forma independiente con la supervivencia fueron metástasis ganglionares (HR = 2,01; IC, 1,01-3,97), tumores pobremente diferenciados (HR = 4,82, IC, 1,65-14,01) y tumores indiferenciados (HR = 9,91, IC, 2,77-35,49). Después de la cirugía radical, los pacientes con y sin metástasis ganglionar tuvieron una supervivencia a cinco años del 44% frente al 59%, respectivamente (p no ajustado = 0,09; p ajustado = 0,11), con datos insuficientes de supervivencia a diez años.LIMITACIONES:El estudio es un análisis retrospectivo e incluye solo hospitales acreditados por la Comisión de Cáncer. El seguimiento a largo plazo fue limitado. La mayoría de los pacientes analizados no tenían invasión linfovascular.CONCLUSIONES:La escisión local para pacientes seleccionados con tumores neuroendocrinos rectales >2 cm es una alternativa viable a la cirugía radical. El estado ganglionar y el grado del tumor predicen de forma independiente la supervivencia y deben tenerse en cuenta en la selección de la intervención quirúrgica. En los pacientes de mayor riesgo seleccionados para cirugía radical, la supervivencia fue similar entre los grupos pN0 vs. pN1, lo que posiblemente indica un beneficio de la cirugía radical para estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B455.

Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema.

BACKGROUND: Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery. METHODS: Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium. RESULTS: The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs. CONCLUSION: The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.

A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery.

BACKGROUND: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. METHODS: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15. RESULTS: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. CONCLUSIONS: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase.

BACKGROUND: Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers. METHODS: Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence. RESULTS: The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.

Preoperative predictive risk to cancer quality in robotic rectal cancer surgery.

BACKGROUND: Circumferential resection margin (CRM) involvement is widely considered the strongest predictor of local recurrence after TME. This study aimed to determine preoperative factors associated with a higher risk of pathological CRM involvement in robotic rectal cancer surgery. METHODS: This was a retrospective review of a prospectively maintained database of consecutive adult patients who underwent elective, curative robotic low anterior or abdominoperineal resection with curative intent for primary rectal adenocarcinoma in a tertiary referral cancer center from March 2012 to September 2019. Pretreatment magnetic resonance imaging (MRI) reports were reviewed for all the patients. Risk factors for pathological CRM involvement were investigated using Firth's logistic regression and a predictive model based on preoperative radiological features was formulated. RESULTS: A total of 305 patients were included, and 14 (4.6%) had CRM involvement. Multivariable logistic regression found both T3 >5 mm (OR 6.12, CI 1.35-36.44) and threatened or involved mesorectal fascia (OR 4.54, CI 1.33-17.55) on baseline MRI to be preoperative predictors of pathologic CRM positivity, while anterior location (OR 3.44, CI 0.72-33.13) was significant only on univariate analysis. The predictive model showed good discrimination (area under the receiver-operating characteristic curve >0.80) and predicted a 32% risk of positive CRM if all risk factors were present. CONCLUSION: Patients with pre-operatively assessed threatened radiological margin, T3 tumors with greater than 5 mm extension and anterior location are at risk for a positive CRM. The predictive model can preoperatively estimate the CRM positivity risk for each patient, allowing surgeons to tailor management to improve oncological outcomes.

The quality of lymph node harvests in extralevator abdominoperineal excisions.

BACKGROUND: Lymph node (LN) harvest in colorectal cancer resections is a well-recognised prognostic factor for disease staging and determining survival, particularly for node-negative (N0) diseases. Extralevator abdominoperineal excisions (ELAPE) aim to prevent "waisting" that occurs during conventional abdominoperineal resections (APR) for low rectal cancers, and reducing circumferential resection margin (CRM) infiltration rate. Our study investigates whether ELAPE may also improve the quality of LN harvests, addressing gaps in the literature. METHODS: This retrospective observational study reviewed 2 sets of 30 consecutive APRs before and after the adoption of ELAPE in our unit. The primary outcomes are the total LN counts and rates of meeting the standard of 12-minimum, particularly for those with node-negative disease. The secondary outcomes are the CRM involvement rates. Baseline characteristics including age, sex, laparoscopic or open surgery and the use of neoadjuvant chemoradiotherapy were accounted for in our analyses. RESULTS: Median LN counts were slightly higher in the ELAPE group (16.5 vs. 15). Specimens failing the minimum 12-LN requirements were almost significantly fewer in the ELAPE group (OR 0.456, P = 0.085). Among node-negative rectal cancers, significantly fewer resections failed the 12-LN standard in the ELAPE group than APR group (OR 0.211, P = 0.044). ELAPE led to a near-significant decrease in CRM involvement (OR 0.365, P = 0.088). These improvements were persistently observed after taking into account baselines and potential confounders in regression analyses. CONCLUSION: ELAPE provides higher quality of LN harvests that meet the 12-minimal requirements than conventional APR, particularly in node-negative rectal cancers. The superiority is independent of potential confounding factors, and may implicate better clinical outcomes.

Do We Have to Treat All T3 Rectal Cancer the Same Way?

Chemoradiotherapy (CRT) followed by surgery is the recommended approach in the last years for stage II and III rectal cancer with the intention to decrease the risk of local recurrence. However, fewer patients benefit from this strategy in terms of overall survival and long-term adverse outcomes because T3 rectal cancer has a broad range of prognosis, as shown by recent publications. Many patients with cT3 rectal cancer have a substantial risk of overtreatment with long-term toxicity related to radiotherapy that could be avoided in a subset group of cT3 tumors with good prognosis. These findings raised the question of whether all cT3 rectal cancer should receive preoperative radiotherapy and if a selected cT3 subgroup could be treated by surgery alone. This review addresses the rationale of selecting good prognosis cT3 rectal cancer for surgery alone and analyzes the data to support this recommendation.

Recommendations on Management of Locally Advanced Rectal Cancer During the COVID-19 Pandemic: an Iranian Consensus.

PURPOSE: Today, the rapid outbreak of COVID-19 is the leading health issue. Patients with cancer are at high risk for the development of morbidities of COVID-19. Hence, oncology centers need to provide organ-based recommendations for optimal management of cancer in the COVID-19 era. METHODS: In this article, we have provided the recommendations on management of locally advanced rectal cancer during the COVID-19 pandemic based on our experience in Shohada-e Tajrish Hospital, Iran. RESULTS: We recommend that patients with locally advanced rectal cancer should be managed in an individualized manner in combination with local conditions related to COVID-19. CONCLUSION: Our recommendation may provide a guide for oncology centers of developing countries for better management of locally advanced rectal cancer.

Canadian taTME expert collaboration (CaTaCO) position statement.

INTRODUCTION: Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. METHODS: The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. RESULTS: The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. CONCLUSIONS: Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.

Assessment of T and N staging with MRI3T in lower and middle rectal cancer and impact on clinical strategy.

BACKGROUND: To determine the diagnostic accuracy of preoperative T/N stage using MRI in lower and middle rectal cancer patients and the impacts on clinical decision-making. PATIENTS AND METHODS: There were 354 patients recruited from May 2017 to February 2019. MRI was performed within 2 weeks before surgery. Histopathologic results were evaluated for the postoperative T/N stage and MRI diagnostic accuracy was assessed based on the postoperative histopathologic results. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and Kappa values were used to evaluate MRI diagnostic accuracy and analysis consistency compared with postoperative histopathologic staging. RESULTS: Overall MRI diagnostic accuracy was 78.2% and 56.8% for T1-4 and N0-2 staging. The Kappa values were 0.625 and 0.323 for T1-4 and N0-2 staging, respectively. After combination, MRI diagnostic accuracy was 85% and 69.5% for T and N staging. The Kappa values were 0.693 and 0.4 for T and N staging. The diagnostic accuracy of MRI for treatment decision-making was 79.1%. CONCLUSION: MRI enables a highly accurate preoperative assessment of T stage but only a fairly accurate preoperative assessment of the N stage for rectal cancer with surgery. The diagnostic accuracy of MRI for treatment decision-making is promising.

Serrated polyps of the colon and rectum: Remove or not?

In recent years, the serrated neoplasia pathway where serrated polyps arise as a colorectal cancer has gained considerable attention as a new carcinogenic pathway. Colorectal serrated polyps are histopathologically classified into hyperplastic polyps (HPs), sessile serrated lesions, and traditional serrated adenomas; in the serrated neoplasia pathway, the latter two are considered to be premalignant. In western countries, all colorectal polyps, including serrated polyps, apart from diminutive rectosigmoid HPs are removed. However, in Asian countries, the treatment strategy for colorectal serrated polyps has remained unestablished. Therefore, in this review, we described the clinicopathological features of colorectal serrated polyps and proposed to remove HPs and sessile serrated lesions ≥ 6 mm in size, and traditional serrated adenomas of any size.

Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery.

Importance: Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear. Objective: To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes. Design, Setting, and Participants: This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases. Interventions: Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons. Main Outcomes and Measures: Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores. Results: The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03). Conclusions and Relevance: Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.

Outcomes and Trends in Colorectal Surgery in U.S. Veterans: A 10-year Experience at a Tertiary Veterans Affairs Medical Center.

Introduction: The past decade has witnessed numerous advances in colorectal surgery secondary to minimally invasive surgery, evidence-based enhanced recovery programs, and a growing emphasis on patient-centered outcomes. The purpose of this study is to benchmark outcomes and experiences of patients undergoing colorectal surgery at a tertiary Veterans Affairs Medical Center for a 10-year period. Materials and Methods: Veterans who underwent nonemergent colorectal procedures between 2008 and 2018 were identified using targeted Current Procedural Terminology (CPT) codes and the Computerized Patient Record System. Patient outcomes were captured using the Veterans Affairs Surgical Quality Improvement Program and focused on length of stay and aggregate postoperative morbidity profiles. SAS® Version 9.4 (SAS Institute Inc., Cary, NC) was used for all data analysis with P < .05 used to indicate significance. Results: In total, 327 patients underwent colon/rectal resection at our medical center. Of whom 95% of patients were male and the average age was 66 years. The median length of stay after surgery was 8 days. Within the 30-day postoperative period, the composite morbidity score was 24.1%: most notable being superficial surgical site infections (6.5%), wound dehiscence (4.6%), and pneumonia (3.1%). Over the course of the study period, the laparoscopic approach increased in utilization, with 22.2% of cases performed laparoscopically in 2008 that rose to 61.1% in 2018. Conclusion: Cataloging this decade of practice provides a foundation for future changes in the field of colorectal surgery and in the treatment of veterans. Understanding historical outcomes should help identify areas for ongoing process improvement and guide targeted approaches to quality metrics.

Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Background: Early data suggest that transanal total mesorectal excision (TaTME) is a safe alternative to the abdominal approach for rectal cancer. This study aims to understand the approach to the management of rectal cancer in Canada and to ascertain perspectives on introducing TaTME. Methods: Surgeons were invited to complete a survey that asked about their management practices relating to rectal cancer and their opinions regarding TaTME. Results: Ninety-four surgeons completed the survey (38% response rate). The number of rectal cancer cases handled annually by surgeons varied widely (1­80 cases, median 15 cases). Twenty-seven percent of respondents performed TaTME at the time of the survey, and 43% of those who did not said they planned on learning the technique. Surgeons who performed TaTME felt that a higher annual volume of rectal cancer cases was required to maintain proficiency than did non-TaTME surgeons (median 20 cases [interquartile range (IQR) 15­25 cases] v. 15 cases [IQR 10­20 cases]). Surgeons who performed TaTME also felt that a higher annual volume of TaTME cases was required to maintain proficiency (median 12 cases [IQR 10­19 cases] v. 9 cases [IQR 5­10 cases]). Conclusion: These findings help define the current practice environment for rectal cancer surgeons in Canada and highlight the complex issues associated with learning TaTME.

Contexte: Selon des données préliminaires, l'exérèse totale du mésorectum par voie transanale (ou TaTME, pour transanal total mesorectal excision) est une solution de rechange sécuritaire à l'approche abdominale pour le cancer du rectum. Cette étude vise à faire le point sur le traitement du cancer rectal au Canada et à mesurer l'intérêt à l'endroit de la technique TaTME. Méthodes: Des chirurgiens ont été invités à répondre à un sondage sur leur façon de prendre en charge le cancer rectal et sur leur opinion au sujet de la TaTME. Résultats: Quatre-vingt-quatorze chirurgiens ont répondu au sondage (taux deréponse 38 %). Le nombre de cancer rectaux traités annuellement par chirurgien variait grandement (de 1 à 80 cas, nombre médian 15 cas). Vingt-sept pour cent des participants appliquaient la TaTME au moment du sondage et 43 % de ceux qui ne l'appliquaient pas disait avoir l'intention de s'y initier. Les chirurgiens qui appliquaient la TaTME se disaient d'avis qu'il fallait un volume annuel plus élevé de cas de cancer rectal pour garder la main comparativement aux chirurgiens qui n'appliquaient pas cette technique (nombre médian de 20 cas [éventail interquartile (ÉIQ) 15­25 cas] c. 15 cas [ÉIQ 10­20 cas]). Les chirurgiens qui appliquaient la TaTME ont aussi estimé qu'il fallait un volume annuel plus élevé de cas de TaTME pour garder la main (nombre médian de 12 cas [ÉIQ 10­19 cas] c. 9 cases (ÉIQ 5­10 cas]). Conclusion: Ces observations permettent de mieux définir les pratiques actuelles des chirurgiens qui soignent le cancer rectal au Canada et mettent en lumière les enjeux complexes inhérents à l'apprentissage de la TaTME.

[Research progress on urogenital function preservation in extralevator abdominoperineal resection].

Extralevator abdominoperineal excision (ELAPE) has been suggested to potentially improve oncological outcomes in advanced low rectal cancer patients. However, the urogenital function impairment as one of the main complications deteriorates the quality of life in these patients. The key point to prevent urogenital function impairment is to avoid autonomic nerve injury, including the superior and inferior hypogastric nerve plexus and neurovascular bundle. Three areas should be especially focused during surgery, including the posterolateral aspect of the prostate during the separation of the rectum from prostate, the lateral wall of ischioanal fossa and the area in front of anal canal. Previous presumption supposed that extended resection, though promoting oncologic outcomes, might lead to enlarged injury to surrounding vessels and nerves that deteriorated patients' urogenital function. But recent studies show that postoperative urogenital function outcomes of rectal cancer patients who underwent ELAPE are not inferior to conventional APE after the induction of minimal invasive approaches including laparoscopic and robotic surgery. Their quality of life can be comparable with patients who underwent conventional APE, and are even better in some particular area. Moreover, as further improvement of ELAPE procedure has been made, the concept of individualized ELAPE addressed the importance of personalized surgical procedure based on tumor stage and location, dedicating to avoid injury to vessels and nerves through preserving more surrounding tissues. Urogenital function outcomes, as part of postoperative outcomes, get more and more attention in recent years. We review current studies on urogenital function after ELAPE from anatomy to clinical research, in order to raise surgeons' attention of nerve preservation technique and to improve their understanding of ELAPE procedure.

Rectal NETs and rectosigmoid junction NETs may need to be treated differently.

Neuroendocrine tumors (NETs) are heterogeneous, and the incidence of NETs is rapidly increasing. We observed different survival in patients with rectal NETs and rectosigmoid junction NETs, which are treated similarly. We included patients with rectal and rectosigmoid junction NETs from the SEER database. The 5-year survival was set as the end-point. 6675 patients with rectal NETs and 329 patients with rectosigmoid junction NETs, were eligible for the analysis. Initially, the survival analyses suggested that the 5-year survival significantly differed between the patients with rectal and rectosigmoid junction NETs (HR = 0.82, 95% CI 0.70-0.95; P = .01). Tumor differentiation, an invasion deeper than T2, and lymph node and distant metastases were still important risk factors affecting survival for both location. While, the males showed better survival (HR = 0.69, 95% CI 0.55-0.88; P < .01) and primary tumor surgery had no benefits (P = .56) for patients with rectosigmoid junction NETs. The factors that predict regional lymph node metastases varied by location. In rectal NETs, invasion deeper than T1 and a tumor larger than 1 cm could significantly increase the risk of regional lymph node metastases (all OR > 5, P < .01). In rectosigmoid junction NETs, the risk of regional lymph node metastases was considered significantly higher with invasion deeper than T1 (all OR > 5, P < .01) and a tumor larger than 2 cm (OR = 31.32, 95% CI 2.53-387.57; P < .01). We advocate a clear and consistent definition of the rectosigmoid junction for future studies, and more studies are needed to determine the reason underlying differences between rectum and rectosigmoid junction.

Anal Squamous Cell Carcinoma: Radiation Therapy Alone Must Be Avoided.

BACKGROUND: Anal squamous cell carcinoma (ASCC) is the most common histological subtype of anal cancer. Rates have been observed to increase in recent years. Combined chemoradiotherapy (CCRT) is currently the gold standard of treatment. The aim of this study is to assess ASCC prevalence, treatment trends, and overall survival (OS) in the United States. METHODS: Patients diagnosed with stage I-IV ASCC were identified from the National Cancer Database from 2004 to 2015. The primary outcome was 5-year OS, which was analyzed using Kaplan-Meier survival curves, log-rank test, and Cox proportional hazards models. RESULTS: 34,613 cases were included (stage I: 21.45%; II: 41.00%; III: 31.62%; IV: 5.94%), with an increasing trend in prevalence. CCRT was the most used treatment. Multimodal treatment, combining surgery with CCRT, offered the best OS rates for stage I, II, and IV cancers (I: 84.87%; II: 75.12%; IV: 33.08%), comparable with survival of stage III patients treated with CCRT (III: 61.14%). Radiation alone had the worse OS rates, and on adjusted analysis, radiation treatment alone had the greatest risk of mortality (I: hazard ratio, 2.01; 95% confidence interval, 1.14-3.54; P = 0.016; II: 2.05, 1.44-2.93, P < 0.001; IV: 1.99, 0.99-4.02, P = 0.054). CONCLUSIONS: ASCC has increased in prevalence, notably in stage III and IV disease. Although CCRT is the most commonly used treatment type for all stages of ASCC, multimodal treatment offers better OS in stages I, II, and IV. Treatment with radiation alone offers the worst OS no matter the stage and should no longer be used as a solitary treatment modality.