Search

Background: According to several clinical trials for patients with rectal cancer, laparoscopic surgery significantly reduces intraoperative complications and bleeding compared with laparotomy and demonstrated comparable long‐term results. However, obesity is considered one of the risk factors for increased surgical difficulty, including complication rate, prolonged operation time, and bleeding. Methods: Patients with clinical pathological stage II/III rectal cancer and a body mass index of ≥25 kg/m2 who underwent laparotomy or laparoscopic surgery between January 2009 and December 2013 at 51 institutions participating in the Japan Society of Laparoscopic Colorectal Surgery were included. These patients were divided into major bleeding (>500 mL) group and minor bleeding (≤500 mL) group. The risk factors of major bleeding were evaluated by univariate and multivariate analyses. Results: This study included 517 patients, of which 74 (19.9%) experienced major bleeding. Patient characteristics did not significantly differ between the two groups. The major bleeding group had a longer operative time (p < 0.001) and a larger tumor size than the minor bleeding group (p = 0.011). In the univariate analysis, age >65 years, laparotomy, operative time >300 min, and multivisceral resection were significantly associated with intraoperative massive bleeding. In the multivariate analysis, age >65 years (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.13–4.82), laparotomy (OR, 20.82; 95% CI, 11.56–39.75), operative time >300 min (OR, 5.39; 95% CI, 1.67–132), and multivisceral resection (OR, 10.72; 95% CI, 2.47–64.0) showed to be risk factors for massive bleeding. Conclusion: Age >65 years, laparotomy, operative time >300 min, and multivisceral resection were risk factors for massive bleeding during rectal cancer surgery in patients with obesity. [ABSTRACT FROM AUTHOR]

Aim: Although the oncological impact of lateral lymph node dissection on enlarged lateral lymph nodes has been gradually accepted over the last decade, that on lateral lymph nodes without swelling remains doubtful. This study aimed to develop a prediction model for the future risk of lateral local recurrence and to clarify the value of adding lateral lymph node dissection in locally advanced rectal cancer without enlarged lateral lymph nodes. Methods: This retrospective, multi‐institutional study recruited 812 patients with cStage II/III low rectal cancer without enlarged lateral lymph nodes <7 mm. Total lateral local recurrence was a hypothetical value of future risk of lateral local recurrence when lateral lymph node dissection was never performed. Results: Overall, total lateral local recurrences were observed in 67 patients (8.3%). In the multivariate analyses, the strongest risk factor for total local recurrences was no preoperative chemoradiotherapy (odds ratio [OR][95%Cl]: 33.2 [4.56–241.7], P < 0.001), followed by tumor distance ≤40 mm (OR [95%Cl]: 2.71 [1.51–4.86], P < 0.001) and lateral lymph node 5–7 mm (OR[95%Cl]: 2.38 [1.26–4.48], P = 0.007). In patients with lateral lymph nodes of 5–7 mm, the total lateral recurrence rate was 4.8% after preoperative chemoradiotherapy. Lateral lymph node dissection could reduce from a total lateral local recurrence of 21.6% to an actual lateral local recurrence of 8.0% in patients without preoperative treatment. Conclusion: We introduce a novel prediction model of future risk of lateral local recurrences, which has the potential to enable us to indicate lateral lymph node dissection selectively according to the patients' risks. [ABSTRACT FROM AUTHOR]

Aim: Whether a laparoscopic procedure can contribute to the improvement of clinical outcomes in obese patients with stage II/III rectal cancer compared to an open procedure remains unclear. Objective: This study evaluated the technical and oncological safety of laparoscopic surgery versus open surgery in obese patients (body mass index [BMI] ≥25 kg/m2) with rectal cancer. Patients and Methods: Data were collected from patients with pathological stage II/III rectal cancer and analyzed. Operations were performed via laparoscopic or open surgery from 2009 to 2013. A comparative analysis was performed after applying propensity score matching to the two cohorts (laparoscopic group and open group). The primary endpoint was 3‐y relapse‐free survival (RFS). Results: Overall, 524 eligible cases were collected from 51 institutions. Equal numbers of propensity score‐matched patients were included in the laparoscopic (n = 193) group and open (n = 193) group. Although the rate of D3 lymph node dissection did not differ between the laparoscopic group (87.0%) and the open group (88.6%), the median number of harvested lymph nodes was significantly lower in the laparoscopic group versus open group (17.5 vs 21, P = 0.0047). The median postoperative hospital stay was also significantly shorter in the laparoscopic group (14 d) vs the open group (17 d) (P = 0.0014). Three‐y RFS was not significantly different between the two groups (hazard ratio 1.2454, 95% confidence interval 0.9201–1.6884, P = 0.4689). Conclusion: The short‐ and long‐term results of this large cohort study (UMIN ID: UMIN000033529) indicated that laparoscopic surgery in obese rectal cancer patients has advantageous short‐term outcomes and no disadvantageous long‐term outcomes. [ABSTRACT FROM AUTHOR]

Background: Neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision surgery is a standard treatment for locally advanced rectal cancer (LARC). Tumor-infiltrating lymphocytes (TILs) have been reported to be associated with tumor response; however, this remains to be established. We previously reported that histological changes on biopsy specimens obtained 7 days after starting nCRT are strong predictors of response to nCRT. Methods: The subjects were 208 patients with LARC who received nCRT. TILs on hematoxylin-eosin staining together with immunohistochemical staining of lymphocyte surface markers including CD3, CD4, CD8, and FoxP3 were performed both on the biopsy specimens before and 7 days after starting nCRT. Results: The proportions of patients with high densities of CD3+, CD4+, CD8+, and FoxP3+ cells 7 days after starting CRT were significantly lower than the respective values before starting nCRT (p < 0.0001, p < 0.0001, p = 0.0023, and p = 0.0046). In biopsy specimens obtained before treatment, high-density CD4+ cells and FOXP3+ cells were significantly associated with tumor shrinkage rate. High-density FOXP3+ cells were significantly associated with marked tumor regression. In biopsy specimens obtained 7 days after starting treatment, high-density CD4+ cells were significantly associated with marked tumor regression, tumor regression grade 1, and tumor shrinkage rate. High-density FoxP3+ cells were significantly associated with marked tumor regression and tumor shrinkage rate. Conclusions: In patients who received nCRT for LARC, the evaluations of immunohistochemical staining for CD4+ and FOXP3+ TILs were more intimately related to histological response to CRT and tumor shrinkage rates in biopsy specimens obtained 7 days after starting treatment than in biopsy specimens obtained before CRT. [ABSTRACT FROM AUTHOR]

Regarding the surgical approaches for rectal cancer, many techniques have been reported in randomized controlled trials, meta‐analyses, and reviews of comparisons between two techniques, e.g. open surgery vs laparoscopic surgery, laparoscopic surgery vs robotic surgery, or laparoscopic surgery vs transanal total mesorectal excision. Since robotic surgery and transanal total mesorectal excision were developed after laparoscopic surgery had become an established minimally invasive technique, they have each been compared with laparoscopic surgery. Therefore, a review was performed to compare the surgical outcomes of robotic surgery and transanal total mesorectal excision, and to perform such comparisons among ≥3 of the above mentioned approaches, in the expectation that this review will serve as a reference for aiding treatment selection in future. The results of the current review suggest that all of the examined procedures have advantages and disadvantages, but that there are no decisive factors that could be used to select one procedure over any other. At the present time it cannot be demonstrated that laparoscopic surgery, robotic surgery, transanal total mesorectal excision, or open surgery is superior to the other techniques, and it is important to select the best technique for each patient from among those that a surgeon can perform. It is also important to maintain a flexible attitude that allows new techniques to be adopted as needed in the future. [ABSTRACT FROM AUTHOR]

Aim: To clarify and evaluate the long‐term outcomes of laparoscopic surgery for clinical stage 0/I rectal carcinoma patients. Methods: This single‐arm phase II trial involved accredited surgeons from 43 Japanese institutions. Patients were registered preoperatively. The planned sample size was 490. The primary endpoint was overall survival, and long‐term outcomes were evaluated. Results: A total of 495 patients were registered between February 2008 and August 2010. Eight patients (1.6%) required conversion to open surgery. Sphincter‐preserving procedures were performed in 477 (97%) patients. Positive radial resection margin was found in two (0.4%) patients. Of 490 patients, 22, 314, 38, 115, and one patient had final pathological stages (p‐stage) 0, I, II, III, and IV, respectively. Pathologically, 31.4% (154/490) of the patients did not have p‐stage 0/I. The 5‐year overall survival (OS) rates in p‐stages 0, I, II, and III were 100%, 98%, 97%, and 94%, respectively. The 5‐year OS of all patients at 96.6% (95% CI 94.6‐97.9) was significantly better than the expected 5‐year OS of 81.1% (P <.0001). The 5‐year relapse‐free survival in p‐stages 0, I, II, and III were 100%, 93%, 81%, and 79%, respectively. The 5‐year relapse‐free survival of all patients was 90.1%. Fifty patients (10.2%) had recurrence; lung recurrence was found in 22 patients, local recurrence in 14, liver in seven, distant lymph node in nine, and bone in three. Conclusions: Laparoscopic surgery for clinical stage 0/I rectal carcinoma has feasible long‐term outcomes. (ClinicalTrials.gov No.NCT00635466.) [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to evaluate the short-term surgical outcomes of laparoscopic abdominoperineal resection (APR) for rectal cancer, by comparing it with a case-control series of open APR. Methods: Fourteen patients with rectal cancer who underwent laparoscopic APR between August 2004 and November 2011 were compared with the open APR group of 14 patients matched for age, gender, and surgical procedure. Results: There were no cases of conversion to laparotomy in the laparoscopic APR group and no mortality in either of the groups. The median operation was longer ( P = 0.002), but the median amount of blood loss was smaller ( P = 0.019), in the laparoscopic APR group. The median length of hospital stay of the laparoscopic APR group was 8 days, shorter than that of the open APR group (16 days, P < 0.001). The changes of the WBC count and serum CRP level after operations were significantly smaller in the laparoscopic APR group ( P < 0.05). There were no significant differences between the groups in terms of the perioperative morbidity and readmission rates within 30 days. Conclusion: Patients undergoing laparoscopic APR had superior perioperative outcomes to those undergoing open APR, except for the longer operation. [ABSTRACT FROM AUTHOR]

This study aims to search for independent predictors of lateral node metastasis in low rectal cancers. We analyzed 1,046 patients who underwent curative resection for lower rectal cancer in our prospectively collected database. All lymph nodes were dissected from the fresh specimen, and their locations were documented prospectively according to the classification by the Japanese Society of Cancer of the Colon and Rectum. More than 35% of the patients had demonstrated upward nodal metastasis in the direction of the inferior mesenteric vessels, while 11% demonstrated lateral node metastasis, which was present in 17.3% of patients with T3 and T4 lesions. Multivariate analysis revealed five factors to be statistically significant independent predictors of lateral node metastasis: female sex, tumors that were not well differentiated, pathological T3 and above, positive microscopic lymphatic invasion, and positive mesorectal nodes. Using the variables sex, differentiation, T stage, and mesorectal nodes as risk factors, because these could be elucidated preoperatively, the presence of lateral node metastasis was then analyzed according to the number of positive risk factors. When there were fewer than three positive factors, the risk of lateral nodal spread was low (4.5%). When three or more risk factors were positive, the odds of lateral node metastasis were more than 7.5 times higher ( p < 0.001). The findings of this study provide a scoring system that can be used to guide the clinician to the presence of lateral node metastasis in low rectal cancers. [ABSTRACT FROM AUTHOR]

Background: Total colectomy with ileorectal anastomosis (IRA) for familial adenomatous polyposis (FAP) carries a potential risk of metachronous cancer in the residual rectum. This study evaluated the risk of cancer development in the residual rectum.Methods: Ninety-six patients who underwent initial surgery for prevention and cure of FAP were studied, and a clinicopathologic comparison was conducted between 59 patients who underwent IRA and 24 who underwent total proctocolectomy.Results: The 5-year overall survival rates were 94% after IRA and 95% after total proctocolectomy with no significant difference. The incidence of dense-type rectal polyps (4/17, 24%) was significantly higher in patients who developed metachronous rectal cancer following IRA compared to that in patients who did not (1/39, 3%). Moreover, 60% of patients with dense-type colon polyps developed metachronous rectal cancer compared to 24% in patients without and 80% of those with dense type rectal polyps developed metachronous rectal cancer compared to 25% without. Endoscopic surveillance of the eight Tis or T1 patients was performed at intervals of 6 months to 1 year after IRA but was not performed in three T3 patients for more than 2 years.Conclusions: Effective IRA requires selection of patients without invasive rectal cancer and without dense rectal polyps in whom long-term postoperative follow-up of the residual rectum is possible. [ABSTRACT FROM AUTHOR]

Background: In laparoscopic operations for rectal carcinoma, only a few multicenter studies of a large number of patients have examined the impact of conversion on outcomes and determined risk factors for conversion. This study was designed to evaluate short-term outcomes and risk factors for conversion to open operation in laparoscopic operations for rectal carcinoma. Study Design: A total of 1,073 patients with carcinoma of the rectum and anus who underwent laparoscopic operations were reviewed retrospectively. Patients were collected from 28 institutions. Patients who required conversion during laparoscopic operation were compared with those with completed laparoscopic resection. Results: Conversion rate was 7.3% (n = 78), and patients requiring conversion were considerably heavier (mean body mass index 24.6 versus 22.7) and had a substantially higher rate of low anterior resection (94.9% versus 83.5%). Conversion was also associated with longer operation time (median 295 minutes versus 270 minutes), greater blood loss (median 265 mL versus 80 mL), longer median postoperative hospital stay (20 days versus 14 days), and higher rates of intraoperative (32.1% versus 3.5%) and postoperative (43.6% versus 21.1%) complications. In multivariate analysis, body mass index and rate of low anterior resection were predictive of conversion. Conclusions: Conversion to open operation is associated with greater morbidity than completed laparoscopic resection. Body mass index and the particular laparoscopic procedure are risk factors for conversion, indicating that appropriate patient selection is essential in laparoscopic operations for rectal carcinoma. [Copyright &y& Elsevier]

Background: Patients with stage T4 rectal cancer are known to have poor survival and often require pelvic exenteration (PE). We describe the oncologic outcome of PE for patients with clinical T4 rectal cancer over a 30-year period. Methods: Data for 93 patients with primary rectal cancer who underwent PE between 1975 and 2005 were reviewed retrospectively. Results: Curative resection was performed in 91 patients (97.9%). Estimated 5-year overall survival (OS) and 5-year recurrence-free survival (RFS) rates were 52% and 46%, respectively. Irradiation was administered in 18 patients (19.4%). Local recurrence was observed in 7 patients, of whom 6 had lymph node (LN) involvement. Estimated local recurrence rate at 2 years was 8.6% (2.0% in node-negative and 16.4% in node-positive patients). Multivariate analysis demonstrated that lateral pelvic LN involvement (P = .03), a carcinoembryonic antigen level of >10 ng/dL (P = .04), and lymphovascular invasion (P = .04) were significantly associated with decreased OS. Only lateral pelvic LN involvement was significantly associated with decreased RFS (P = .01). Conclusion: For patients with clinical T4 rectal cancer, PE can provide an opportunity for long-term survival and good local control. Patients with lateral pelvic LN involvement should be offered adjuvant treatment pre- or postoperatively to improve prognosis after PE. [Copyright &y& Elsevier]

Background/Aims: This study investigated appropriate level of upward lymph node (LN) dissection in advanced lower rectal carcinoma. Methods: A total of 285 consecutive patients with stage II/III lower rectal carcinoma were analyzed. LN dissection was classified as follows: division of the root of the superior rectal artery (UD2), division of the root of the inferior mesenteric artery (UD3) and UD3 with para-aortic LN dissection (UD4). Results: LN metastases at the root of the inferior mesenteric artery were found in 4 patients. Their prognoses were worse than those of the other stage III patients (p = 0.011). On the other hand, LN metastases along the superior rectal artery were discovered in 14 patients, whose 5-year overall survival rate was 61.2%. By removing the LNs either UD2 or UD3/4, a similar survival rate was achieved in stage III patients with LN metastases along the superior rectal artery. Conclusion: Survival of a minority with metastatic LNs at the root of the inferior mesenteric artery was poor. Additionally, survival is no worse in patients with positive LN along the superior rectal artery as long as these positive nodes are resected by either UD2 or UD3/4. Low ligation is adequate for advanced lower rectal carcinoma. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: To investigate the efficacy of laparoscopic surgery for rectal cancer in obese and older patients, who are often characterized by a higher prevalence of comorbidities and physical decline.This large-scale multicenter retrospective cohort study included 524 patients with a body mass index of 25 or higher who underwent either open or laparoscopic surgery for stage II or III rectal cancer between 2009 and 2013. We assessed the short-term outcomes and relapse-free survival by comparing these surgical modalities. The patients were stratified into 404 non-elderly (< 70 years) and 120 elderly (≥ 70 years) patients.In both patient groups, laparoscopic surgery was associated with a significantly reduced blood loss (non-elderly: 41 vs. 545 ml; elderly: 50 vs. 445 ml) and shorter hospital stays (non-elderly: 10 vs. 19 days; elderly: 15 vs. 20 days) than open surgery. The overall complications and relapse-free survival showed no significant differences between the two surgical techniques in either age group. Additionally, the impact of the laparoscopic procedure on the relapse-free survival remained consistent between the age groups.Laparoscopic surgery offers short-term benefits for patients with obesity and rectal cancer compared to open surgery, regardless of age, without influencing the long-term prognosis.Methods: To investigate the efficacy of laparoscopic surgery for rectal cancer in obese and older patients, who are often characterized by a higher prevalence of comorbidities and physical decline.This large-scale multicenter retrospective cohort study included 524 patients with a body mass index of 25 or higher who underwent either open or laparoscopic surgery for stage II or III rectal cancer between 2009 and 2013. We assessed the short-term outcomes and relapse-free survival by comparing these surgical modalities. The patients were stratified into 404 non-elderly (< 70 years) and 120 elderly (≥ 70 years) patients.In both patient groups, laparoscopic surgery was associated with a significantly reduced blood loss (non-elderly: 41 vs. 545 ml; elderly: 50 vs. 445 ml) and shorter hospital stays (non-elderly: 10 vs. 19 days; elderly: 15 vs. 20 days) than open surgery. The overall complications and relapse-free survival showed no significant differences between the two surgical techniques in either age group. Additionally, the impact of the laparoscopic procedure on the relapse-free survival remained consistent between the age groups.Laparoscopic surgery offers short-term benefits for patients with obesity and rectal cancer compared to open surgery, regardless of age, without influencing the long-term prognosis.Results: To investigate the efficacy of laparoscopic surgery for rectal cancer in obese and older patients, who are often characterized by a higher prevalence of comorbidities and physical decline.This large-scale multicenter retrospective cohort study included 524 patients with a body mass index of 25 or higher who underwent either open or laparoscopic surgery for stage II or III rectal cancer between 2009 and 2013. We assessed the short-term outcomes and relapse-free survival by comparing these surgical modalities. The patients were stratified into 404 non-elderly (< 70 years) and 120 elderly (≥ 70 years) patients.In both patient groups, laparoscopic surgery was associated with a significantly reduced blood loss (non-elderly: 41 vs. 545 ml; elderly: 50 vs. 445 ml) and shorter hospital stays (non-elderly: 10 vs. 19 days; elderly: 15 vs. 20 days) than open surgery. The overall complications and relapse-free survival showed no significant differences between the two surgical techniques in either age group. Additionally, the impact of the laparoscopic procedure on the relapse-free survival remained consistent between the age groups.Laparoscopic surgery offers short-term benefits for patients with obesity and rectal cancer compared to open surgery, regardless of age, without influencing the long-term prognosis.Conclusion: To investigate the efficacy of laparoscopic surgery for rectal cancer in obese and older patients, who are often characterized by a higher prevalence of comorbidities and physical decline.This large-scale multicenter retrospective cohort study included 524 patients with a body mass index of 25 or higher who underwent either open or laparoscopic surgery for stage II or III rectal cancer between 2009 and 2013. We assessed the short-term outcomes and relapse-free survival by comparing these surgical modalities. The patients were stratified into 404 non-elderly (< 70 years) and 120 elderly (≥ 70 years) patients.In both patient groups, laparoscopic surgery was associated with a significantly reduced blood loss (non-elderly: 41 vs. 545 ml; elderly: 50 vs. 445 ml) and shorter hospital stays (non-elderly: 10 vs. 19 days; elderly: 15 vs. 20 days) than open surgery. The overall complications and relapse-free survival showed no significant differences between the two surgical techniques in either age group. Additionally, the impact of the laparoscopic procedure on the relapse-free survival remained consistent between the age groups.Laparoscopic surgery offers short-term benefits for patients with obesity and rectal cancer compared to open surgery, regardless of age, without influencing the long-term prognosis. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the incidence and patterns of recurrence, or oncologic safety, after intersphincteric resection (ISR) without radiotherapy for very low rectal adenocarcinoma. Study Design: One hundred eight consecutive patients with T1–T3 rectal cancers located 1 to 5 cm (median 3 cm) from the anal verge underwent ISR. A retrospective analysis of prospectively recorded data from the 106 patients not receiving radiotherapy was performed. Results: There were 23 T1, 40 T2, and 43 T3 tumors. Morbidity and mortality rates were 33% and 1%, respectively. The 3-year rates of overall local recurrence and survival were 5.7% and 95%, respectively. The 3-year cumulative local recurrence rate was 0% for the patients with T1–T2 tumors as compared with 15% for those with T3 tumors (p=0.0012). In T3 tumors, the 2-year local recurrence rate was 5% for patients with negative surgical margins as compared with 33% for those with positive margins (p=0.0001). The incidences of distant recurrence for stages I, II, III, and IV disease were 4%, 5%, 18%, and 33%, respectively. Conclusions: ISR does not increase local or distant recurrences. For T1–T2 tumors, meticulous dissection and irrigation after closure of the distal stump allows local control without radiotherapy. With T3 tumors, preoperative therapy should be considered if resection margins are estimated to be insufficient. [Copyright &y& Elsevier]