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Background: Multidisciplinary treatment of rectal cancer, including neoadjuvant treatment, total mesorectal excision, and adjuvant chemotherapy, have improved oncological outcome. Preoperative radiation therapy is advocated by national and international guidelines in all patients with AJCC stage II and III rectal cancer. Although this treatment reduces local recurrence rates with no effect on overall survival, there are possible short- and long-term side effects of radiation exposure, so patients should be carefully selected for neoadjuvant radiation therapy., Methods: We analyzed whether ventral or dorsal tumor location affects local recurrence rates following radical rectal resection. Patients who underwent radical rectal resection for mid or low rectal cancer in our department between October 2001 and December 2013 were included. Prognostic indicators for local recurrence were analyzed using univariate and multivariate analyses., Results: Overall, 480 patients met the inclusion criteria. Univariate analysis identified surgical procedure (hazard ratio [HR] 1.9, p = 0.006), ventral tumor location (HR 3.8, p < 0.001), and a pathologic circumferential resection margin (pCRM) (HR 9.3, p < 0.001) as prognostic factors of local recurrence. Multivariate analysis revealed tumor location (HR 3.5, p < 0.001) and pCRM (HR 6.0, p = 0.002) as independent factors for local recurrence. Neoadjuvant treatment of AJCC stage II and III tumors reduced the local recurrence rate at ventral but not at dorsal tumor locations (p < 0.001)., Conclusions: Ventral versus dorsal tumor location is an independent prognostic factor for local recurrence. Tumor location may aid in patient selection for neoadjuvant treatment.

Background: Pelvic exenteration (PE) is a complex and challenging surgical procedure. The reported results of this procedure for primary and recurrent disease are limited and conflicting., Methods: This study analyzed patient outcomes after all PEs performed in the authors' department between October 2001 and December 2016. Relevant patient data were obtained from a prospective database. Morbidity and mortality were reported for all patients. For patients with malignant disease, differences in perioperative outcomes, prognostic indicators for overall survival, and local and systemic disease recurrence were analyzed using uni- and multivariate analyses., Results: The study enrolled 187 patients. Of the 183 patients with malignant disease, 63 (38.2%) had primary locally advanced tumors and 115 (62.5%) had recurrent tumors. The 10-year overall survival rate was 63.5% for the patients with primary tumors that were curatively resected and 20.9% for the patients with recurrent disease (p = 0.02). The 10-year survival rate for the patients with extrapelvic disease who underwent curative resection was 37%. Multivariable analysis identified margin positivity (p < 0.01), surgery lasting longer than 7 h (p = 0.02), and recurrent disease (p < 0.01) as predictors of poor survival. Multivariate analysis of local and systemic disease recurrence showed recurrent disease (p < 0.01) as the only significant prognostic factor., Conclusions: Pelvic exenteration has good long-term results, even for patients with extrapelvic disease. The oncologic outcome for patients with recurrent disease is worse than for patients with primary disease. However, even for these patients, long-time survival is possible.

Background: Anastomotic leakage is the most dreaded complication after rectal resection and total mesorectal excision, leading to increased morbidity and mortality. Formation of a diverting ileostomy is generally performed to protect anastomotic healing. Identification of variables predicting anastomotic leakage might help to select patients who are under increased risk for the development of anastomotic leakage prior to surgery. The objective of this study was to assess the applicability of a nomogram as prognostic model for the occurrence of anastomotic leakage after rectal resection in a cohort of rectal cancer patients., Methods: Nine hundred seventy-two consecutive patients who underwent surgery for rectal cancer were retrospectively analyzed. Univariate and multivariable Cox regression analyses were used to determine independent risk factors associated with anastomotic leakage. Receiver operating characteristics (ROC) curve analysis was performed to calculate the sensitivity, specificity, and overall model correctness of a recently published nomogram and an adopted risk score based on the variables identified in this study as a predictive model., Results: Male sex (p = 0.042), obesity (p = 0.017), smoking (p = 0.012), postoperative bleeding (p = 0.024), and total protein level ≤ 5.6 g/dl (p = 0.007) were identified as independent risk factors for anastomotic leakage. The investigated nomogram and the adopted risk score failed to reach relevant areas under the ROC curve greater than 0.700 for the prediction of anastomotic leakage., Conclusions: The proposed nomogram and the adopted risk score failed to reliably predict the occurrence of anastomotic leakage after rectal resection. Risk scores as prognostic models for the prediction of anastomotic leakage, independently of the study population, still need to be identified.

Background: While several trials have compared laparoscopic to open surgery for colon cancer showing similar oncological results, oncological quality of laparoscopic versus open rectal resection is not well investigated., Methods: A systematic literature search for randomized controlled trials was conducted in MEDLINE, the Cochrane Library, and Embase. Qualitative and quantitative meta-analyses of short-term (rate of complete resections, number of harvested lymph nodes, circumferential resection margin positivity) and long-term (recurrence, disease-free and overall survival) oncologic results were conducted., Results: Fourteen randomized controlled trials were identified including 3528 patients. Patients in the open resection group had significantly more complete resections (OR 0.70; 95% CI 0.51-0.97; p = 0.03) and a higher number of resected lymph nodes (mean difference - 0.92; 95% CI - 1.08 to 0.75; p < 0.001). No differences were detected in the frequency of positive circumferential resection margins (OR 0.82; 95% CI 0.62-1.10; p = 0.18). Furthermore, no significant differences of long-term oncologic outcome parameters after 5 years including locoregional recurrence (OR 0.95; 95% CI 0.44-2.05; p = 0.89), disease-free survival (OR 1.16; 95% CI 0.84-1.58; p = 0.36), and overall survival (OR 1.04; 95% CI 0.76-1.41; p = 0.82) were found. Most trials exhibited a relevant risk of bias and several studies provided no information on the surgical expertise of the participating surgeons., Conclusion: Differences in oncologic outcome between laparoscopic and open rectal surgery for rectal cancer were detected for the complete resection rate and the number of resected lymph nodes in favor of the open approach. No statistically significant differences were found in oncologic long-term outcome parameters.

Purpose: Intersphincteric resection (ISR) is an alternative to abdominoperineal resection (APR) for a selected subset of patients with low rectal cancer, combining equivalent oncological outcome and sphincter preservation. However, functional results are heterogeneous and often imperfect. The aim of the present investigation was to determine the long-term functional results and quality of life after ISR., Methods: One hundred forty-three consecutive patients who underwent surgery for low rectal cancer were analysed. Sixty patients received ISR and 83 patients APR, respectively. Kaplan-Meier estimate was used to analyse patients' survival. The EORTC QLQ-C30, -C29 and the Wexner score were used to determine functional outcome and quality of life., Results: ISR and APR were both associated with comparable morbidity and no mortality. Patients' disease- and recurrence-free survival after ISR and APR were similar (p = 0.2872 and p = 0.4635). Closure of ileostomy was performed in 73% of all patients after ISR. Long-term outcome showed a rate of incontinence (Wexner score ≥10) in 66% of the patients. Despite this, patients' quality of life was significantly better after ISR compared to APR in terms of abdominal complaints and psycho-emotional functioning., Conclusions: ISR is technically feasible with acceptable postoperative morbidity rates. Functional results following ISR are compromised by incontinence as the most important complication. However, long-term quality of life is superior to APR, which should be considered when selecting patients for ISR.

Background: Current guidelines advocate that all rectal cancer patients with American Joint Committee on Cancer (AJCC) stages II and III disease should be subjected to neoadjuvant therapy. However, improvements in surgical technique have resulted in single-digit local recurrence rates with surgery only., Methods: Operative, postoperative, and oncological outcomes of patients with and without neoadjuvant therapy were compared between January 2002 and December 2013. For this purpose, all patients resected with low anterior rectal resection (LAR) and total mesorectal excision (TME) who had or had not been irradiated were identified from the authors' prospectively maintained database. Patients who were excluded were those with high rectal cancer or AJCC stage IV disease; in the surgery-only group, patients with AJCC stage I disease or with pT4Nx rectal cancer; and in the irradiated patients, patients with ypT4Nx or cT4Nx rectal cancer., Results: Overall, 454 consecutive patients were included. A total of 342 (75 %) patients were irradiated and 112 (25 %) were not irradiated. Median follow-up for all patients was 48 months. Among patients with and without irradiation, pathological circumferential resection margin positivity rates (2.9 vs. 1.8 %, p = 0.5) were not different. At 5 years, in irradiated patients compared with surgery-only patients, the incidence of local recurrence was decreased (4.5 vs. 3.8 %, p = 0.5); however, systemic recurrences occurred more frequently (10 vs. 17.8 %, p = 0.2). Irradiation did not affect overall or disease-free survival (neoadjuvant treatment vs. surgery-only: 84.9 vs. 88.2 %, p = 0.9; 76 vs. 79.1 %, p = 0.8)., Conclusions: The current study adds to the growing evidence that suggests a selective rather than generalized indication for neoadjuvant treatment in stages II and III rectal cancer.

Background: Local recurrence of rectal cancer after curative surgery predicts patients' prognosis. The correlation between the exact anatomic location of tumour recurrence and patients' survival is still under debate. Thus, this study aimed to investigate the impact of the exact location of recurrent rectal cancer on post-operative morbidity and survival., Methods: This is a retrospective study including 90 patients with locally recurrent rectal cancer. The location of tumour recurrence was classified into intraluminal and extraluminal recurrence. Univariate and multivariable Cox regression analyses were used to determine the impact on post-operative morbidity and survival., Results: Patients' survival with intraluminal recurrence was significantly longer compared to patients with extraluminal recurrence (p = 0.027). Curative resection was associated with prolonged survival in univariate and multivariable analyses (p = 0.0001) and was more often achieved in patients with intraluminal recurrence (p = 0.024). Survival of curative resected patients with intraluminal recurrence was significantly longer compared to curatively resected patients with extraluminal recurrence (p = 0.0001). The rate of post-operative morbidity between intraluminal and extraluminal recurrence was not statistically different (p = 0.59)., Conclusion: Based on the present investigation, intraluminal recurrence is associated with superior outcome. Post-operative morbidity did not differ significantly between both groups.

Background: Whether anastomotic leakage (AL) has a negative impact on survival remains a matter of debate. This study aimed to assess the impact of AL on the overall and disease-free survival of patients undergoing curative resection of stages 1-3 rectal cancer using propensity-scoring methods., Methods: In a single-center study, 570 patients undergoing curative resection of stages 1-3 rectal cancer between January 2002 and December 2011 were assessed. The mean follow-up period was 4.7 ± 2.9 years. Patients who did and did not experience AL were compared using Cox regression and propensity score analyses., Results: Overall, 51 patients (8.9 %) experienced an AL. The characteristics of the patients were highly biased concerning AL (propensity score, 0.16 ± 0.12 vs. 0.09 ± 0.07; P < 0.001). Anastomotic leakage was uniformly associated with a significantly increased risk of mortality in unadjusted analysis [hazard ratio (HR) 2.30; 95 % confidence interval (CI) 1.40-3.76; P = 0.003], multivariable Cox regression (HR 2.27; 95 % CI 1.33-3.88; P = 0.005), and propensity score-adjusted Cox regression (HR 2.07; 95 % CI 1.21-3.55; P = 0.014). Similarly, disease-free survival was significantly impaired in patients who experienced AL according to unadjusted analysis (HR 1.88; 95 % CI 1.19-2.95; P = 0.011), multivariable Cox regression (HR 1.90; 95 % CI 1.17-3.09; P = 0.014), and propensity score-adjusted Cox regression (HR 2.31; 95 % CI 1.40-3.80; P = 0.002)., Conclusions: This is the first propensity score-based analysis providing evidence that oncologic outcome may be impaired after curative rectal cancer resection in patients with AL.

Background: Radical resection with total mesorectal excision (TME) is the accepted standard of care for most rectal cancers. However, T1 rectal cancers may be at low risk for metastases and are therefore treatable with local resection. The aim of our study was to investigate whether the identification of these patients is possible through existing selection criteria., Methods: Between 2001 and 2012, radical resection with TME was performed in 68 patients with a histologically confirmed T1 adenocarcinoma of the rectum. Each patient was staged preoperatively as lymph node negative. Patients at low risk to metastasize were defined as proposed by Hermanek and Gall (Int J Colorectal Dis 1(2):79-84, 1986), Kikuchi et al. (Dis Colon Rectum 38(12):1286-1295, 1995) and Hase et al. (Dis Colon Rectum 38(1):19-26, 1995) Postoperative morbidity, mortality, and oncological outcome were analyzed., Results: Despite nodal negative staging, 9 of 68 patients (13 %) were node positive. Following the proposal of Hermanek and Gall, Kikuchi et al., and Hase et al., 14 % (5/37), 12 % (3/26), and 16 % (6/38) of patients, respectively, with low-risk tumors had lymph node metastases. In the univariate analysis, none of the investigated parameters could predict lymph node metastases. Following radical resection, none of the patients, regardless of nodal involvement, developed a recurrence., Conclusions: Preoperative diagnostics regarding lymphatic tumor propagation and histomorphological assessment of tumor samples as predictors of lymph node metastasis are unreliable. Following radical resection with TME, the oncological outcome of node-positive patients with T1 rectal adenocarcinoma is comparable with that of lymph node-negative patients. Considering the lymph node metastases rate, a local excision should always be complemented with additional therapy.

Background: This investigation assessed the baseline mortality-adjusted 5-year survival after open rectal cancer resection., Methods: The 5-year survival rate was analyzed in 885 consecutive American Joint Committee on Cancer (AJCC) stage I-IV rectal cancer patients undergoing open resection between 2002 and 2011 using risk-adjusted Cox proportional hazards regression models adjusted for population-based baseline mortality., Results: The 5-year relative and overall survival rates were 80.9%(95% confidence interval (CI): 77.0-85.0%) and 71.9%(95% CI, 68.4-75.5%), respectively. The 5-year relative survival rates for stage I, II, III, and IV cancer were 97.8% (95% CI, 93.1-102.8%), 90.9%(95% CI, 84.3-98.1%), 72.0% (95% CI, 64.7-80.1%), and 24.4% (95% CI: 16.0-37.0%), respectively. After the curative resection of stage I-III rectal cancer, fewer than every other observed death was cancer-related. The 5-year relative survival rate for stage I cancer did not differ from the matched average national baseline mortality rate (P = 0.419). Higher age (hazard ratio (HR) 0.94, 95% CI: 0.92-0.95, P < 0.001) was protective for relative survival but unfavorable for overall survival (HR 1.04, 95% CI: 1.02-1.05, P < 0.001). Female gender was only unfavorable for relative survival (HR 1.59, 95% CI: 1.11-2.29, P = 0.014)., Conclusion: The analysis of relative survival in a large cohort of rectal cancer patients revealed that stage I rectal cancer is fully curable. The findings regarding age and gender may explain the conflicting results obtained to date from studies based on overall survival.