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Background: Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types., Objective: To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology., Design: This was a retrospective comparative study., Setting: This study was conducted at a large, tertiary referral institution., Patients: Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded., Main Outcome Measures: The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques., Results: A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05)., Limitations: This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size., Conclusion: Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal., Antecedentes: La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos., (Copyright © The ASCRS 2021.)

Background: Neoadjuvant chemoradiotherapy (nCRT) has become the standard of care for locally advanced rectal cancer, decreasing locoregional recurrence, yet with an unclear survival advantage. We aimed to assess the benefit of nCRT on oncologic and perioperative outcomes of patients with clinical stage IIA rectal adenocarcinoma treated with abdominoperineal resection (APR)., Methods: Patients with clinical T3N0 rectal adenocarcinoma that underwent APR between 1995 and 2014 were included. Patients who received nCRT were compared with patients who did not. Multivariate analysis was conducted to compare oncological and perioperative outcomes between the groups., Results: 127 patients were included, of which 94 received nCRT. Median follow-up was 11.9 years. There was no difference in circumferential margins, postoperative morbidity, and complication rates between the groups. There was no difference in 5-year oncological outcomes between the groups., Conclusions: No difference was found in 5-year oncological outcomes between patients with clinical T3N0 rectal adenocarcinoma necessitating an APR who received nCRT and those not receiving nCRT, with similar overall complication rates., Competing Interests: Declaration of competing interest The authors have no relevant disclosures. This study did not receive any financial support., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Our aim was to develop a nomogram taking into account factors such as tumor biology to predict overall and disease-free survival for patients with primary rectal adenocarcinoma undergoing curative intent surgical resection., Methods: Patients undergoing resection for primary rectal adenocarcinoma (2007-2017) were included. Factors reflecting tumor biology and important clinical prognosticators were included in nomogram development. Prognostic factors were assessed with multivariable analysis using Cox regression. The impact of each was assessed using Kaplan Meier survival curves., Results: Overall, 1688 patients (male, 61%) with a mean age of 59.8 years (±13.5) and a median follow-up of 34.8 months (range, 12-132) were included. The only significant factors affecting the overall and disease-free survival were age at diagnosis, pathological staging, regression grade, resection margin, and tumor deposits., Conclusion: The current model incorporates histopathological and clinical factors. It emphasizes the importance of tumor biological factors like tumor deposits in predicting overall and disease-free survival in rectal cancer., Summary: Rectal cancer outcomes are associated with certain clinical and pathological factors that can be evaluated. Tumor deposits are one such factor that can affect overall and disease-free survival., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Controversial data exists in the current literature in regard to the use of neoadjuvant chemoradiation (nCRT) in patients with clinical T3N0 (cT3N0) rectal cancers, specifically based on location and relation to peritoneal reflection. We aimed to analyze the impact of nCRT on oncologic outcomes among cT3N0 rectal cancers, depending on the tumor height from anal verge (AV)., Methods: A retrospective analysis of patients with cT3N0 rectal cancers was included from a query of a prospectively maintained rectal cancer database from 1980 to 2016. Patients were divided into 3 groups based on the tumor height: low (1-5 cm from AV), mid (6-10 cm from AV), and upper (11-15 cm from AV). Patients were stratified by use of nCRT., Main Outcomes: 5-year overall survival (OS), disease-free survival (DFS), cancer-specific survival (CSS), and local recurrence (LR) using Kaplan-Meier curves., Results: Five hundred ninety-two patients were included. Overall, 364 (61.4%) patients received nCRT and 228 (38.6%) patients did not. There were 251 (43%) patients with low, 302 (51%) with mid, and 39 (7%) with upper rectal cancer. Patients with low and mid rectal cancers received nCRT more frequently than those with upper rectal cancers (68.5% and 61.2% vs 43.6%, p = 0.007). The 5-year OS was 78% and 63%, DFS-88% and 73%, LR-1% and 8% in nCRT followed by resection vs. surgery alone (p < 0.001). In regard to cancer location after nCRT compared with surgery alone, low and mid cancers had better OS, DFS, and CSS, compared with upper ones., Conclusion: nCRT prolongs survival among patients with rectal cancer below 10 cm from AV; however, it has no effect on 5-year oncologic survival of patients with upper rectal cancer located below peritoneal reflection.

Introduction: The optimal management of patients with radiologically positive lateral pelvic lymph nodes in locally advanced rectal cancer remains unclear. We compared local recurrence rates and oncological outcomes of patients with locally advanced cancer with and without lateral pelvic lymph nodes., Methods: Patients who underwent curative surgery for stage III rectal adenocarcinoma between 2009 and 2014 and had a preoperative MRI at our institution as well as preoperative neoadjuvant treatment were included. Patients with positive lateral pelvic lymph nodes (iliac or obturator nodes) on preoperative MRI (LPND +) were compared to patients with no lateral pelvic nodal disease (LPND -). Data were collected from a prospectively maintained institutional database. Differences between the groups were compared in univariate analysis. Log-rank test was used to evaluate overall and disease-free survival between the groups., Results: A total of 125 patients met inclusion criteria with a mean age of 56.3 ± 12.2 and 75% were male. Median follow-up was 44 months (IQR 32, 106). Positive LPND was present on preoperative MRI in 43/125 (34.4%) patients who were in the LPND (+) group. Seventeen out of 43 patients had a post-neoadjuvant treatment MRI and 15 patients had a decrease in size of nodes or disappearance of LPND. On univariate analysis, LPND (+) and LPND (-) groups were comparable. Local recurrence rates were higher in the LPND (+) group, although this was not statistically significant (16.3% vs. 6%, p = 0.06). Overall and disease-free survival rates were comparable between the LPND (+) and LPND (-) groups (p = 0.97, p = 0.51)., Conclusions: Management of patients with advanced rectal cancer and radiologically positive lateral pelvic lymph nodes is challenging due to high local recurrence rates. Further studies are needed to develop care pathways for the optimal treatment processes.

Background: The completeness of the resected mesorectum is a quality metric in rectal cancer surgery and has been related to oncological outcomes. Our aim was to identify variables associated with non-complete mesorectal excision and determine any effect on overall survival., Methods: Consecutive patients who underwent curative intent surgery for rectal adenocarcinoma (2009-2016) were identified from a prospectively-maintained institutional database. Patients were grouped according to their mesorectal grade: complete, near-complete and incomplete. Multivariate analysis was performed to identify the association between various patient, disease and surgeon-related characteristics and mesorectal grading. Log-rank tests were used to evaluate any difference in overall survival between the groups., Results: 689 patients met inclusion criteria. Demographics and perioperative variables were comparable between the groups. On multivariate analysis, abdominoperineal resection, and involved circumferential resection margin were significantly associated with non-complete mesorectum. Finally, patients with non-complete mesorectal grading have approximately twice the hazard of death compared to those with complete mesorectal grading., Conclusions: Several factors are associated with a non-complete mesorectal excision. Non-complete mesorectal grade is associated with decreased survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Rationale and Objectives: The objective of this study was to develop and quantitatively evaluate a radiology-pathology fusion method for spatially mapping tissue regions corresponding to different chemoradiation therapy-related effects from surgically excised whole-mount rectal cancer histopathology onto preoperative magnetic resonance imaging (MRI)., Materials and Methods: This study included six subjects with rectal cancer treated with chemoradiation therapy who were then imaged with a 3-T T2-weighted MRI sequence, before undergoing mesorectal excision surgery. Excised rectal specimens were sectioned, stained, and digitized as two-dimensional (2D) whole-mount slides. Annotations of residual disease, ulceration, fibrosis, muscularis propria, mucosa, fat, inflammation, and pools of mucin were made by an expert pathologist on digitized slide images. An expert radiologist and pathologist jointly established corresponding 2D sections between MRI and pathology images, as well as identified a total of 10 corresponding landmarks per case (based on visually similar structures) on both modalities (five for driving registration and five for evaluating alignment). We spatially fused the in vivo MRI and ex vivo pathology images using landmark-based registration. This allowed us to spatially map detailed annotations from 2D pathology slides onto corresponding 2D MRI sections., Results: Quantitative assessment of coregistered pathology and MRI sections revealed excellent structural alignment, with an overall deviation of 1.50 ± 0.63 mm across five expert-selected anatomic landmarks (in-plane misalignment of two to three pixels at 0.67- to 1.00-mm spatial resolution). Moreover, the T2-weighted intensity distributions were distinctly different when comparing fibrotic tissue to perirectal fat (as expected), but showed a marked overlap when comparing fibrotic tissue and residual rectal cancer., Conclusions: Our fusion methodology enabled successful and accurate localization of post-treatment effects on in vivo MRI., (Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: The impact of rectal cancer tumor height on local recurrence and metastatic spread is unknown. The objective was to evaluate the impact of rectal cancer tumor height from the anal verge on metastatic spread and local recurrence patterns., Methods: The Norwegian nationwide surgical quality registry was reviewed for curative rectal cancer resections from 1/1/1996-12/15/2006. Cancers were stratified into five height groups: 0-3 cm, >3-5 cm, >5-9 cm, >9-12 cm, 12 cm-HI. Competing risk and proportional hazards models assessed the relationship between tumor height and patterns of metastasis and survival., Results: 6859 patients were analyzed. After median follow-up of 52 months (IQR 20-96), 26.7% (n = 1835) experienced recurrence. With tumors >12 cm, the risk of liver metastases increased (crude HR 1.49, p = 0.03), while lung metastases decreased (crude HR 0.66, p = 0.03), and risk of death decreased (crude HR 0.81, p = 0.001) The cumulative incidence of pelvic recurrence were highest for the low tumors (p = 0.01). Median time to liver metastases was 14months (IQR 7-24), lung metastases 25months (IQR 13-39), pelvic recurrence 19months (IQR10-32), (p < 0.0001). Time to metastases in liver and lungs were significantly associated with tumor height (p < 0.001) CONCLUSION: There are distinct differences in metastatic recurrence patterns and time to recurrence from different anatomic areas of the rectum. In crude analyses, tumor height impacted metastatic spread to the liver and lungs. However, when adjusting for treatment variables, the hazard of metastatic spread to the liver and lungs are limited. Nevertheless, time to metastases in liver and lungs is significantly impacted by tumor height. Venous drainage of the rectal cancer may be a significant contributor of rectal cancer metastatic spread, but further research is warranted., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The feasibility of a laparoscopic approach in patients who have had a prior laparotomy (PL) remains controversial. We hypothesized that laparoscopic colorectal resection was safe and feasible in patients with previous open abdominal surgery., Methods: A retrospective review (2007-2015) of all patients undergoing laparoscopic resection for sigmoid and rectal adenocarcinoma with or without prior midline laparotomy (NPL) was performed. Primary endpoints included conversion and perioperative morbidity. Secondary endpoints included length of stay and perioperative outcomes. Demographics, surgical history, oncologic staging, and short-term outcomes were reviewed., Results: We identified 211 patients, of whom 33 (15.6%) had a prior laparotomy. Significantly more patients in the PL group were female (76.2 vs. 52.8%, p = 0.004). Patients with PL were of similar age to NPL patients (69.3 vs. 62.5, p = 0.09), and comorbidities, tumor staging, and neoadjuvant therapy were comparable between groups (all p > 0.05). Additional trocar placement was significantly higher in PL group (33.3 vs. 17.4%, p = 0.03), while conversion rate did not reach statistical significance (24.2 vs. 12.9%, p = 0.08). The postoperative complication rate was comparable between PL and NPL patients (33.3 vs. 25.3%, respectively, p = 0.2)., Conclusions: Prior laparotomy should not be a contraindication to patients undergoing laparoscopic colorectal surgery, though surgeons should anticipate a higher likelihood of conversion to open.

Introduction: Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR., Methods: A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated., Results: There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients., Conclusions: APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To establish a structured international expert consensus on a detailed technical description of the laparoscopic total mesorectal excision (TME)., Background: Laparoscopic TME is a common surgical approach for the treatment of rectal cancer, but there is little agreement on technical details and standards., Methods: Sixty leading surgical experts from 5 different world regions with a median overall experience of 250 laparoscopic TME participated in this study. Four stages of mixed quantitative and qualitative consensus-finding methods were applied. (1) Semistructured expert interviews were independently analyzed by 2 assessors. (2) Consensus on the interview data was reached using reiterating questionnaires (Delphi method). (3) This was further refined in an interactive workshop. (4) Based on this meeting, a comprehensive text was drafted and final approval was sought by all experts., Findings: Three theme categories were identified in 9 detailed interviews (anatomical landmarks, description of tissue retraction, and operating strategies). Following 2 rounds of a 54-item questionnaire, 29 items achieved very high agreement (A* ≥90%), 14 with good agreement (≥80%), 13 with moderate agreement (≥50%), and 18 with little or no agreement (<50%). In the workshop, areas of agreement were consolidated and conclusions were sought for those with less agreement. The final document was approved after 2 further rounds of surveys by all respondents., Conclusions: This detailed and agreed technical description of laparoscopic TME may have implications on training, assessment, quality control, and future research.

Background: Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated., Methods: A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation., Results: Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma., Conclusions: Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches., Methods: A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach., Results: The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77%) and 19 open (23%) procedures. Nine laparoscopic procedures (14.5%) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2%; P = 0.450) and overall survival periods (93.5 vs. 90.9%; P = 0.766). The local recurrence rate was 2.5%., Conclusions: Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.

Background and Objectives: The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes., Methods: Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach., Results: Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43)., Conclusions: LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.

Background: There is an increasing trend to use laparoscopy for rectal cancer surgery. Although laparoscopic and open rectal resections appear oncologically equivalent, there is little information on the cost of different surgical approaches. With the current health care crisis and the importance of optimizing health care resources and patient outcomes, the cost of care is an important factor., Objective: The aim of this study was to evaluate the cost-effectiveness of laparoscopy in rectal cancer., Design: This was a case-matched study., Settings: This study was conducted at a tertiary referral center., Patients: Patients undergoing elective rectal cancer resection between 2007 and 2012 were selected., Methods: A review of a prospective database for elective laparoscopic rectal cancer resections was performed. Laparoscopic cases were matched to open cases based on age, BMI, operative procedure, and diagnostic-related group., Main Outcome Measures: The primary outcomes measured were the cost of care, hospital length of stay, discharge disposition, readmission, postoperative complications, and mortality rates., Results: Two hundred fifty-four matched cases were included in the analysis: 125 laparoscopic (49%) and 129 open (51%). The cTNM stage (p = 0.39), tumor distance from the anal verge (p = 0.07), and rate of neoadjuvant therapy received between the laparoscopic and open groups were similar (p = 0.12). Operating time (p< 0.01) and cost per operating room minute (p = 0.04) were significantly higher in the open group. The groups were oncologically equivalent, based on circumferential resection margin (p = 0.15). The laparoscopic group had a significantly shorter length of stay (p < 0.01) and lower total hospital cost (p < 0.01). Postoperative complications, 30-day readmission, reoperation, and mortality rates were similar. However, significantly more patients undergoing open resection required intensive care unit care (p = 0.03), skilled nursing (p = 0.03), or home care services (p < 0.01) at discharge., Limitations: This investigation was conducted at a single institution and it is a retrospective study with potential bias., Conclusions: Laparoscopy is cost-effective for rectal cancer surgery, improving both health care expenditures and patient outcomes. For selected patients, laparoscopic rectal cancer resection can reduce length of stay, operating time, and resource utilization.

This video demonstrates a laparoscopic abdominal perineal resection for a fixed 4.8-cm mass involving the posterior and left rectal walls and left puborectalis, 2 cm from the anal verge (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A127). We detail the steps of the procedure, all completed in lithotomy, including lateral-to-medial dissection; identification and protection of the left ureter and presacral nerves; division of the inferior mesenteric artery; medial-to-lateral dissection, with meeting the previous dissection plane; total mesorectal excision and pelvic dissection; perineal dissection and layered closure; and abdominal inspection and colostomy creation. Total operative time was 181 minutes. The specimen total mesorectal excision was complete with a negative circumferential radial margin (greater than 1 cm). Final pathology was T3N2M0.

The role of laparoscopic proctectomy in rectal cancer has not clearly been defined. Publications on long-term outcomes after laparoscopic proctectomy is lacking and there is a wide variation of practice patterns of rectal cancer management. Current data supports the feasibility of laparoscopic proctectomy for rectal cancer but due to surgeon, patient and tumor related factors open technique may be favored. Current series suggest that laparoscopic proctectomy can be performed with similar oncologic adequacy with regards to, circumferential resection margin, distal margin, local recurrence and quality of life. Ongoing trials will provide evidence clarifying the role of laparoscopic proctectomy in rectal cancer. Until then, high-level laparoscopic skills and meticulous preoperative evaluation of both patient and tumor can identify appropriate candidates.

Background: Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described., Methods: We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers., Results: Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as "15 cm from the verge." Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001)., Conclusions: Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Endoscopic radiofrequency ablation (RFA) has been used effectively for ablation of foregut disorders and also may have a role in treating colonic pathology. This study aimed to assess the feasibility of delivering RFA to locations within the colon and to determine a range of safe treatment parameters., Methods: Patients undergoing left hemicolectomy or proctocolectomy were evaluated. Focal RFA using a colonoscope-mounted device was delivered to normal segments of the colon and rectum within the planned surgical resection specimen. Endoscopic accessibility and feasibility of delivering heat energy to the colon and rectum were assessed as well as the maximum incurred histologic depth of ablation in relation to the number of applications (2 or 4) and the energy density (12, 15, or 20 J/cm2)., Results: A total of 51 ablation zones in 16 patients had available histopathology. None of the sites receiving two applications demonstrated serosal layer alteration compared with 15% of the sites receiving four applications (p=0.11). Muscularis propria alterations were seen in 25% of the two-application sites and 63% of the four-application sites (p<0.05). Increasing energy density from 12 to 20 J/cm2 did not correlate with a deeper ablation effect., Conclusions: Endoscopic RFA is capable of delivering therapy to the distal colon. Injury is limited to the muscularis propria or less depth when no more than two ablations are applied regardless of the energy density used. Based on these feasibility and dosimetry results, the authors will continue investigation using these and smaller energy doses to initiate trials ultimately with patients who have suitable mucosal and submucosal disorders of the lower gastrointestinal tract including chronic, nonulcerated hemorrhagic radiation proctitis and angiodyplasia.

Background: Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates., Methods: One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer., Results: One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81)., Conclusions: There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.

Introduction: Laparoscopic rectal resection (LRR) has not gained the same acceptance as laparoscopic segmental colonic resection because of technical challenges, increased operating time and costs, and concerns about the oncological outcome., Discussion: One way to overcome these challenges is by standardizing the laparoscopic technique in the same way as has been done with the open rectal cancer surgery. We have established a standardized, stepwise laparoscopic procedure for rectal resections that enhances the transformation of laparoscopic skills, identifies indications for conversion early in the operation, and makes the operation predictable and reproducible for the whole surgical team., Conclusion: We believe this saves time in the operating room and builds up laparoscopic team expertise.

Objective: To examine the effect of preoperative radiotherapy (PRT) on patients who undergo rectal resection with total mesorectal excision (TME) for stage T3 low rectal cancers., Summary Background Data: Evidence for the value of PRT before rectal cancer surgery is weakened by variability in the use of TME. Many surgeons have concluded that PRT is unnecessary for small rectal tumors if TME is performed, but there are no prospective data to support this opinion., Methods: Since 1980, 2,200 patients with rectal cancer have been enrolled in a prospective database. Of these, 259 underwent curative anterior or abdominoperineal resection with TME for pathologically confirmed T3 lesions within 8 cm of the anal verge. Patients were grouped by receiving PRT (n = 92) or not receiving PRT (n = 167). Five-year overall survival and 5-year local recurrence rates were evaluated., Results: Overall survival was increased from 52% in patients not receiving PRT to 63% in those receiving PRT. PRT increased overall survival for node-negative patients from 58% to 82%, with no benefit for node-positive patients. There was no significant difference in local recurrence rates. When categorized by tumor size, there was no difference in overall survival or local recurrence for 0- to 2-cm tumors or those larger than 5 cm, but PRT increased overall survival from 50% to 72% for patients with 2- to 5-cm tumors. Similar results were observed for patients with tumors staged as T3 on preoperative endoluminal ultrasound., Conclusions: Patients with pT3 low rectal cancers undergoing resection with TME have an improved survival with PRT. The effect is most beneficial for patients with node-negative and 2- to 5-cm tumors, although this group may include larger and node-positive tumors that have been downstaged by PRT. PRT should be advocated for all patients with T3 rectal cancers less than 8 cm from the anal verge, even if the surgery includes a properly performed TME.