Learning curve for robotic-assisted total mesorectal excision: a multicentre, prospective study.

AIM: Robotic-assisted surgery (RAS) is becoming increasingly important in colorectal surgery. Recognition of the short, safe learning curve (LC) could potentially improve implementation. We evaluated the extent and safety of the LC in robotic resection for rectal cancer. METHOD: Consecutive rectal cancer resections (January 2018 to February 2021) were prospectively included from three French centres, involving nine surgeons. LC analyses only included surgeons who had performed more than 25 robotic rectal cancer surgeries. The primary endpoint was operating time LC and the secondary endpoint conversion rate LC. Interphase comparisons included demographic and intraoperative data, operating time, conversion rate, pathological specimen features and postoperative morbidity. RESULTS: In 174 patients (69% men; mean age 62.6 years) the mean operating time was 334.5 ± 92.1 min. Operative procedures included low anterior resection (n = 143) and intersphincteric resection (n = 31). For operating time, there were two or three (centre-dependent) LC phases. After 12-21 cases (learning phase), there was a significant decrease in total operating time (all centres) and an increase in the number of harvested lymph nodes (two centres). For conversion rate, there were two or four LC phases. After 9-14 cases (learning phase), the conversion rate decreased significantly in two centres; in one centre, there was a nonsignificant decrease despite the treatment of significantly more obese patients and patients with previous abdominal surgery. There were no significant differences in interphase comparisons. CONCLUSION: The LC for RAS in rectal cancer was achieved after 12-21 cases for the operating time and 9-14 cases for the conversion rate. RAS for rectal cancer was safe during this time, with no interphase differences in postoperative complications and circumferential resection margin.

Early and late morbidity of local excision after chemoradiotherapy for rectal cancer.

BACKGROUND: Local excision (LE) after chemoradiotherapy is a new option in low rectal cancer, but morbidity has never been compared prospectively with total mesorectal excision (TME). Early and late morbidity were compared in patients treated either by LE or TME after neoadjuvant chemoradiotherapy for rectal cancer. METHOD: This was a post-hoc analysis from a randomized trial. Patients with clinical T2/T3 low rectal cancer with good response to the chemoradiotherapy and having either LE, LE with eventual completion TME, or TME were considered. Early (1 month) and late (2 years) morbidities were compared between the three groups. RESULTS: There were no deaths following surgery in any of the three groups. Early surgical morbidity (20 per cent LE versus 36 per cent TME versus 43 per cent completion TME, P = 0.025) and late surgical morbidity (4 per cent versus 33 per cent versus 57 per cent, P < 0.001) were significantly lower in the LE group than in the TME or the completion TME group. of LE, was associated with the lowest rate of early (10 versus 18 versus 21 per cent, P = 0.217) and late medical morbidities (0 versus 7 versus 7 per cent, P = 0.154), although this did not represent a significant difference between the groups. The severity of overall morbidity was significantly lower at 2 years after LE compared with TME or completion TME (4 versus 28 versus 43 per cent grade 3-5, P < 0.001). CONCLUSION: The rate of surgical complications after neoadjuvant chemoradiotherapy in the LE group was half that of TME group at 1 month and 10 times lower at 2 years. LE is a safe approach for organ preservation and should be considered as an alternative to watch-and-wait in complete clinical responders and to TME in subcomplete responders.

Low-pressure versus standard pressure laparoscopic colorectal surgery (PAROS trial): a phase III randomized controlled trial.

TRIAL DESIGN: This is a phase III, double-blind, randomized, controlled trial. METHODS: In this trial, patients with laparoscopic colectomy were assigned to either low pressure (LP: 7 mmHg) or standard pressure (SP: 12 mmHg) at a ratio of 1 : 1. The aim of this trial was to assess the impact of low-pressure pneumoperitoneum during laparoscopic colectomy on postoperative recovery. The primary endpoint was the duration of hospital stay. The main secondary endpoints were postoperative pain, consumption of analgesics and postoperative morbidity. RESULTS: Some 138 patients were enrolled, of whom 11 were excluded and 127 were analysed: 62 with LP and 65 with SP. Duration of hospital stay (3 versus 4 days; P = 0.010), visual analog scale (0.5 versus 2.0; P = 0.008) and analgesic consumption (level II: 73 versus 88 per cent; P = 0.032; level III: 10 versus 23 per cent; P = 0.042) were lower with LP. Morbidity was not significantly different between the two groups (10 versus 17 per cent; P = 0.231). CONCLUSION: Using low-pressure pneumoperitoneum in laparoscopic colonic resection improves postoperative recovery, shortening the duration of hospitalization and decreasing postoperative pain and analgesic consumption. This suggests that low pressure should become the standard of care for laparoscopic colectomy. TRIAL REGISTRATION: NCT03813797.

The aim of this trial was to assess the impact of low-pressure pneumoperitoneum during laparoscopic colectomy. The study proved that using low pressure in laparoscopic colonic resection improves postoperative recovery, decreasing length of hospitalization, postoperative pain and analgesic consumption.

International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis.

BACKGROUND: Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. METHODS: An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. RESULTS: Among 154 patients (97 in France and 57 in Australia), 31·8 per cent had ymrT4 disease and 68·2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0·112). The concordance in operative planning was low (κ = 0·314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0·001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0·002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0·007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0·139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0·047), and a lower level of distress at 6 months (P = 0·049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. CONCLUSION: This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.

ANTECEDENTES: La extensión del tumor más allá del plano del meso-rrecto (ymrT4) ocurre en el 5-10% de los pacientes con cáncer de recto y el 10% de los pacientes desarrollan recidiva local del cáncer de recto (locally recurrent rectal cáncer, LRRC) después de una cirugía primaria. Existe una variación global en la prestación de la asistencia sanitaria para esta pato-logía. MÉTODOS: Se realizó un ensayo de referencia internacional sobre el manejo de ymrT4 y LRRC en Francia y Australia entre 2015 y 2017. La heterogeneidad en el manejo y la toma de decisiones quirúrgicas se analizaron mediante la comparación de las tasas de resección quirúrgica, la lectura a ciegas de la resonancia magnética (RM) pélvica entre países, la evaluación de la calidad de vida y las evaluaciones cualitativas. RESULTADOS: De 154 pacientes (97 en Francia versus 57 en Australia), el 32% tenía ymrT4 y el 68% tenía cáncer de recto con recidiva local. Las tasas de resección quirúrgica fueron del 87,6% versus 77,8% (P = 0,112). La tasa de concordancia en la decisión quirúrgica fue baja (coeficiente kappa = 0,314) con una tasa más baja de exenteración pélvica en Francia, tanto en la práctica clínica (46% versus 85%; P < 0,0001) como en condiciones teóricas (40% versus 88%; P = 0,002). La tasa de resección R0 fue menor en Francia para la LRRC (51% versus 86%, P = 0,007) pero no para el ymrT4 (81% versus 100%, P = 0,139). Las tasas de morbilidad fueron similares. Los pacientes que se sometieron a procedimientos no exenterativos tuvieron una subescala de funcionamiento mental más alta a los 12 meses (P = 0,04) y un nivel de angustia más bajo a los 6 meses (P = 0,04). El análisis cualitativo destacó 5 categorías de factores psicosociales que afectaron a la decisión del tratamiento: paciente, estrategia, especialista, organización y cultura. CONCLUSIÓN: Este ensayo de referencia internacional destaca las diferencias en el tratamiento mundial del cáncer de recto localmente avanzado y de la LRR. La aten-ción estandarizada debería mejorar los resultados para estos pacientes.

Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25-year experience from Bordeaux.

AIM: There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period. METHOD: This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤ 6 cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied. RESULTS: Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0 cm (P < 0.001) and the distal resection margin shortened from 25 to 10 mm (P < 0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9% vs 3.5%; P = 0.741) and disease-free survival (72% vs 71% vs 75%; P = 0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction. CONCLUSION: Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.

Delayed coloanal anastomosis: an alternative option for restorative rectal cancer surgery after high-dose pelvic radiotherapy for prostate cancer.

AIM: Restorative total mesorectal excision (TME) for rectal cancer after high-dose pelvic radiotherapy for prostate cancer has been reported to provide an unacceptable rate of pelvic sepsis. In a previous publication we proposed that delayed coloanal anastomosis (DCAA) should be performed in this situation. The present study aimed to assess the feasibility and outcomes of this strategy. METHOD: Between 2000 and 2018, 1094 men were operated on for rectal cancer in our institution. All men with T2/T3 mid and low rectal cancer with preoperative radiotherapy and restorative TME were considered for this study (n = 416). Patients with external-beam high-dose radiotherapy (EBHRT) for prostate cancer (70-78 Gy) were identified and compared with patients with conventional long-course chemoradiotherapy (CRT) followed by TME. We compared our already published historical cohort (2000-2012), including arm A (CRT + TME; n = 236) and arm B (EBHRT + TME; n = 12), with our early cohort (2013-2018), including arm C (CRT + TME; n = 158) and arm D (EBHRT + TME-DCAA; n = 10). The end-points were morbidity, pelvic sepsis, reoperation rate and quality of the specimen. RESULTS: Overall morbidity was not significantly different between groups. Pelvic sepsis decreased from 50% (arm B) to 10% (arm D) with the use of DCAA (P = 0.074), and was similar between arms A, C and D. Quality of the specimen was not significantly different between the four groups. CONCLUSION: Our results suggest that TME with DCAA in patients with previous EBHRT is feasible, with the same postoperative pelvic sepsis rate as conventional CRT.

Randomized trial comparing low-pressure versus standard-pressure pneumoperitoneum in laparoscopic colectomy: PAROS trial.

BACKGROUND: Laparoscopy, by its minimally invasive nature, has revolutionized digestive and particularly colorectal surgery by decreasing post-operative pain, morbidity, and length of hospital stay. In this trial, we aim to assess whether low pressure in laparoscopic colonic surgery (7 mm Hg instead of 12 mm Hg) could further reduce pain, analgesic consumption, and morbidity, resulting in a shorter hospital stay. METHODS AND ANALYSIS: The PAROS trial is a phase III, double-blind, randomized controlled trial. We aim to recruit 138 patients undergoing laparoscopic colectomy. Participants will be randomly assigned to either a low-pressure group (7 mm Hg) or a standard-pressure group (12 mm Hg). The primary outcome will be a comparison of length of hospital stay between the two groups. Secondary outcomes will compare post-operative pain, consumption of analgesics, morbidity within 30 days, technical and oncological quality of the surgical procedure, time to passage of flatus and stool, and ambulation. All adverse events will be recorded. Analysis will be performed on an intention-to-treat basis. TRIAL REGISTRATION: This research received the approval from the Committee for the Protection of Persons and was the subject of information to the ANSM. This search is saved in the ID-RCB database under registration number 2018-A03028-47. This research is retrospectively registered January 23, 2019, at http://clinicaltrials.gov/ed under the name "LaPAroscopic Low pRessure cOlorectal Surgery (PAROS)". This trial is ongoing.

Morbidity and oncological outcomes of rectal cancer impaired by previous prostate malignancy.

BACKGROUND: Specific surgical and oncological outcomes in patients with rectal cancer surgery after a previous diagnosis of prostate cancer have not been well described. The aim of this study was to compare surgical outcomes in patients with rectal cancer with or without a history of prostate cancer. METHODS: Patients who had surgery for rectal cancer with (PC group) or without (no-PC group) previous curative treatment for prostate cancer were enrolled between January 2001 and December 2015. Comparisons between the two groups were performed by multivariable Cox analysis, and after propensity score matching in a 3 : 1 ratio for demographic and tumour characteristics, and surgical and oncological outcomes. RESULTS: A total of 944 patients with rectal cancer were enrolled, of whom 10·8 per cent had a history of prostate cancer. After matching, 83 patients who had received treatment for prostate cancer were compared with 249 who had not. The PC and no-PC groups were similar regarding patient characteristics. Extended total mesorectal excision, conversion to open surgery, transfusion and tumour perforation were more frequent in the PC group than in the no-PC group. Major surgical morbidity (28 versus 17·2 per cent; P = 0·036), anastomotic leakage (25 versus 13·7 per cent; P = 0·019) and permanent stoma (41 versus 12·4 per cent; P < 0·001) occurred more frequently in the PC group. Local recurrence was increased significantly in the PC group (17 versus 8·0 per cent; P = 0·019), and resulted in a significant decrease in disease-free and overall survival. CONCLUSION: Prostate cancer treatment increases short- and long-term surgical morbidity in patients with rectal cancer, and impairs oncological outcomes.

[Rectal cancer radiotherapy: Therapeutical strategy and perspective]. / La radiothérapie des cancers du rectum : stratégie thérapeutique et perspective.

Standard treatment consisting of chemoradiotherapy followed by radical surgery with total mesorectal excision, resulting in good oncologic local control but high morbidity and poor functional results. The same treatment applied to all patients presenting with low or mid T3-4 rectal tumors could result in overtreatment of small tumors. However, it remains insufficient (or unsatisfactory?) for locally advanced tumors regarding metastatic recurrence rate. Treatment is decided by a multidisciplinary board on the basis of initial staging, including MRI which allows for resection margin prediction and post-treatment response evaluation. The therapeutic strategy is changing towards upfront chemotherapy and therapeutic desescalation omitting radiotherapy or surgery in a rectal preservation strategy. Moreover, tumor response leads to new multidisciplinary board discussion and treatment adaptation.

Session 3: Many ways to organ preserve the rectum but which is correct?

From the patient's perspective, cancer cure with full preservation of function is a crucial goal. There are many advances that have emerged which may make this possible in a greater proportion of patients without compromising oncological outcomes. Professor Tekkis reviews the options and evidence to date for 'organ preservation' and the expert panel discuss the implications for current and future patient care.

Organ preservation in rectal cancer: a synopsis of current guidelines.

BACKGROUND: The high morbidity associated with radical resection for rectal cancer is an incentive for surgeons to adopt strategies aimed at organ preservation, particularly for early disease. There are a number of different approaches to achieve this. In this study we have collated current national and international guidelines to produce a synopsis to support this changing practice. METHODS: The databases PubMed, Embase, Trip database, national guideline clearinghouse, BMJ Best practice were interrogated. Guidelines published before 2010 were excluded. The AGREE-II tool was used for quality assessment. RESULTS: 24 guidelines were drawn from 2278 potential publications. A consensus exists for local excision for "low risk" T1 rectal cancer but there is no agreement how to stratify the risk of treatment failure. There is a low level of agreement for rectal preservation for more advanced disease but when mentioned is recommended for unfit patients or in th context of a clinical trial. Guidelines are inconsistent with respect to surveillance in node negative disease and after, complete response to chemoradiotherapy CONCLUSION: According to current guidelines and consensus statements organ preservation for rectal cancer beyond low risk T1, is still considered experimental and only indicated in patients unsuitable for radical surgery.. Follow up strategies and cN0 staging deserve attention and highlight the need for high quality clinical trials. This article is protected by copyright. All rights reserved.

The effect of adjuvant chemotherapy on survival and recurrence after curative rectal cancer surgery in patients who are histologically node negative after neoadjuvant chemoradiotherapy.

AIM: The aim of this study was to evaluate whether adjuvant chemotherapy will affect recurrence rate or disease-free and overall survival in patients with rectal adenocarcinoma who were staged with MRI node-positive disease (mrN+) preoperatively. These patients underwent neoadjuvant chemoradiotherapy with curative rectal cancer surgery and their pathological staging was negative for nodal disease (ypN0). There is no consensus on the role of adjuvant chemotherapy in such patients. METHOD: Patients who received neoadjuvant chemoradiotherapy and underwent curative rectal cancer surgery for rectal adenocarcinoma staged as [mrTxN+M0] on MRI staging and who on pathological staging were found to be [ypTxN0M0] were retrospectively identified from January 2008 December 2012 from two tertiary referral centres (Royal Marsden Hospital, London and Saint-Andre Hospital, Bordeaux). RESULTS: One hundred and sixty-three patients were recruited and, after propensity matching at a ratio of 2:1, n = 80 patients were divided to receive adjuvant (n = 28) or no adjuvant treatment (n = 52). A comparison of adjuvant chemotherapy vs no adjuvant therapy showed that the mean overall survival was 2.67 vs 3.60 years (P = 0.42) and disease-free survival was 2.27 vs 3.32 years (P = 0.14). CONCLUSION: This study found no significant difference in survival or disease recurrence between patients who received adjuvant chemotherapy and patients who did not. There is no clear evidence to support or dismiss the use of adjuvant chemotherapy for patients who were node positive on preoperative MRI and node negative on histopathological staging. Further multicentre prospective randomized trials are needed to identify the appropriate treatment regime for this group of patients.

Individualizing surgical treatment based on tumour response following neoadjuvant therapy in T4 primary rectal cancer.

BACKGROUND: Rectal cancer involving at least one adjacent organ (mrT4b) requires multi-visceral resection to achieve clear resection margin (R0). Performing pelvic compartment preservation according to the tumour response has not been considered. This study assesses the impact of changing the surgical strategy according to tumour response in rectal cancer mrT4b. METHODS: Patients with non-metastatic T4b rectal cancer at two tertiary referral centres between 2008 and 2013 were grouped as "Responders" ypT0-3abNx versus "Non-responders" ypT3cd-4Nx and divided into three surgical procedures: total mesorectal excision (TME), extended-TME (eTME) and beyond-TME (b-TME). End-points were circumferential resection margin, postoperative morbidity, definitive stoma formation, 3-years local recurrence (3y-LR) and 3-years disease-free survival (3y-DFS) according to both tumours' response and surgical procedures. RESULTS: Among 883 patients with rectal cancer, 101 were included. Responders had a higher rate of induction chemotherapy (59.7% vs. 38.2%; p = 0.04). Morbidity and definitive stoma formation were significantly higher in Non-responders. R0 was not impacted by either the tumour response or the surgical procedures. The 3y-LR was lower in Responders (14%) compared to Non Responders (32%) (HR 1.6; 95% CI: 1.02-2.59; p = 0.041), and was two-fold higher in e-TME compared to b-TME in Non-responders, whereas no difference was found in Responders. The 3y-DFS was higher in Responders irrespective to the surgery (71% vs. 47%; p = 0.07). CONCLUSION: In Responders, TME or e-TME are technically and oncollogically feasible and should be considered in preferrence to b-TME. In Non-responders, allowing for high rates of morbidity and local recurrence in patients with e-TME, b-TME procedures should be preferred.

The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer.

AIM: The long-term risk of definitive stoma after sphincter-saving resection (SSR) for rectal cancer is underestimated and has never been reported for ultralow conservative surgery. We report the 10-year risk of definitive stoma after SSR for low rectal cancer. METHOD: From 1994 to 2008, patients with low rectal cancer who were suitable for SSR were analysed retrospectively. Patients were divided into the following four groups: low colorectal anastomosis (LCRA); coloanal anastomosis (CAA); partial intersphincteric resection (pISR); and total intersphincteric resection (tISR). The end-point was the risk of a definitive stoma according to the type of anastomosis. RESULTS: During the study period, 297 patients had SSR for low rectal cancer. The incidence of definitive stoma increased from 11% at 1 year to 22% at 10 years. The reasons were no closure of the loop ileostomy (4.7%), anastomotic morbidity (6.5%), anal incontinence (8%) and local recurrence (5.2%). The risk of definitive stoma was not influenced by type of surgery: 26% vs 18% vs 18% vs 19% (P = 0.578) for LCRA, CAA, pISR and tISR, respectively. Independent risk factors for definitive stoma were age > 65 years and surgical morbidity. CONCLUSION: The risk of a definitive stoma after SSR increased two-fold between 1 and 10 years after surgery, from 11% to 22%. Ultralow conservative surgery (pISR and tISR) did not increase the risk of definitive stoma compared with conventional CAA or LCRA.

Is there still a need for prophylactic intra-abdominal drainage in elective major gastro-intestinal surgery?

Prophylactic drainage of the abdominal cavity after gastro-intestinal surgery is widely used. The rationale is that intra-abdominal drainage enhances early detection of complications (gastro-intestinal leakage, hemorrhage, bile leak), prevents collection of fluid or pus, reduces morbidity and mortality, and decreases the duration of hospital stay. However, dogmatic attitudes favoring systematic drain placement should be questioned. The aim of this review was to evaluate the evidence supporting systematic use of prophylactic abdominal drainage following gastrectomy, pancreatectomy, liver resection, and rectal resection. Based on this review of the literature: (i) there was no evidence in favor of intra-peritoneal drainage following total or sub-total gastrectomy with respect to morbidity-mortality, nor was it helpful in the diagnosis or management of leakage, however the level of evidence is low, (ii) following pancreatic resection, data are conflicting but, overall, suggest that the absence of drainage is prejudicial, and support the notion that short-term drainage is better than long-term drainage, (iii) after liver resection without hepatico-intestinal anastomosis, high level evidence supports that there is no need for abdominal drainage, and (iv) following rectal resection, data are insufficient to establish recommendations. However, results from the French multicenter randomized controlled trial GRECCAR5 (NCT01269567) should provide new evidence this coming year. Accumulating data support that systematic drainage of the abdominal cavity in digestive surgery is a non-beneficial and obsolete practice, except following pancreatectomy where the consensus appears to indicate the usefulness of short-term drainage. While the level of evidence is high for liver resections, new randomized controlled trials are awaited regarding gastric, pancreatic and rectal surgery.

French current management and oncological results of locally recurrent rectal cancer.

BACKGROUND: There is a significant worldwide variation in practice regarding the criteria for operative intervention and overall management in patients with locally recurrent rectal cancer (LRRC). A survival benefit has been described for patients with clear resection margins in patients undergoing surgery for LRRC which is seen as an important surgical quality indicator. METHODS: A prospective French national database was established in 2008 which recorded procedures undertaken for locally recurrent rectal cancer (LRRC). Overall and Disease-Free Survival (OS, DFS) were assessed retrospectively. We report the variability and the heterogeneity of LRRC management in France as well as 5-year oncological outcomes. RESULTS: In this national report, 104 questionnaires were completed at 29 French surgical centres with a high variability of cases-loaded. Patients had preoperative treatment in 86% of cases. Surgical procedures included APER (36%), LAR (25%), Hartmann's procedure (21%) and pelvic exenterations (15.5%). Four patients had a low sacrectomy (S4/S5). There were no postoperative deaths and overall morbidity was 41%. R0 was achieved in 60%, R1 and R2 in 29% and 11%, respectively. R0 resection resulted in a 5-year OS of 35% compared to 12% and 0% for respectively R1 and R2 (OR = 2.04; 95% CI: 1.4-2.98; p < 0.001). OS was similar between R2 and non-resected patients (OR = 1.47; 95% CI: 0.58-3.76; p = 0.418). CONCLUSIONS: Our data is in accordance with the literature except the rate of extended resection procedures. This underlines the selective character of operative indications for LRRC in France as well as the care variability and the absence of optimal clinical pathway regarding these patients.

[Organ preserving strategies for rectal cancer treatment]. / Stratégies de préservation d'organe dans le traitement des cancers du rectum.

For rectal cancers, the current standard of care consists of chemoradiation followed by radical surgery with total mesorectal excision. Oncologic results are good, especially regarding local recurrence rates, but at the cost of high morbidity rates and poor anorectal, urinary and sexual function results. Since chemoradiation yields 15 to 25% pathological complete response, the role of radical surgery is questioned for patients presenting with good response after chemoradiation and two organ preservation strategies have been offered: watch and wait strategy and local excision strategy. The aim of this review is to give the results of organ preservation after chemoradiotherapy series and to highlight different questions regarding initial patient's selection, complete clinical response definition, risk of mesorectal nodal involvement, follow-up modalities as well as oncologic and functional results.

Surgery for rectal cancer after high-dose radiotherapy for prostate cancer: is sphincter preservation relevant?

AIM: The feasibility and outcome of sphincter-saving resection for rectal cancer were assessed in patients previously treated by high-dose radiotherapy for prostate cancer. METHOD: Between 2000 and 2012, 1066 patients underwent rectal excision for rectal cancer. Of these, 236 were treated by conventional radiotherapy (45 Gy) and sphincter-saving resection (Group A) and 12 were treated by external-beam radiotherapy (EBRT) for prostate cancer (70 Gy) and sphincter-saving resection (Group B) of whom five had a metachronous and seven a synchronous cancer. The end-points were surgical morbidity, pelvic sepsis, reoperation and definitive stoma. RESULTS: Tumour characteristics were similar in both groups. Surgical morbidity (67% vs 25%, P = 0.004), anastomotic leakage (50% vs 10%, P = 0.001, and reoperation (50% vs 17%, P = 0.011) were significantly higher in Group B. Multivariate analyses showed that EBRT for prostate cancer was the only independent factor for anastomotic leakage (OR = 5.12; 95% CI 1.45-18.08; P = 0.011) and definitive stoma (OR = 10.56; 95% CI 3.02-39.92; P < 0.001). CONCLUSION: High-dose radiotherapy for prostate cancer increases morbidity from rectal surgery and the risk of a permanent stoma. This suggests that a delayed coloanal anastomosis or a Hartmann procedure should be proposed as an alternative to low anterior resection in this population.