Sphincter Saving Surgeries for Locally Advanced Low Rectal Cancer after Neoadjuvant Chemoradiation

Mohamed A. E. Salem, Hamza A. Hamza, Gamal Amira, Abeer E. Ibrahium, Ahmed A. S. Salem

Medical Oncology Department, South Egypt Cancer Institute, Assiut University, Assiut, Egypt.
Radiation Oncology Department, South Egypt Cancer Institute, Assiut University, Assiut, Egypt.
Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt.
Surgical Oncology Department, South Egypt Cancer Institute, Assiut University, Assiut, Egypt.

DOI: 10.4236/jct.2013.47143                

Abstract

Background: Rectal cancer accounts for the largest distribution within one anatomical region of the large bowel, with approximately one third of all CRC located within the rectum. The Golden standard treatment of primary rectal cancer is curative surgical resection; however, a fine balance remains between disease cure and restoration of gastrointestinal continuity. Combined modality has proven efficacy in many malignant tumors with advantage of organ preservation. Methods: Forty nine (49) patients with low rectal carcinoma were included in a prospective study, between Jan 2007 and Jan 2012. Preoperative chemoradiation was administrated to all patients and subjected to different techniques of sphincter saving surgery. Stage I and Stage IV disease at diagnosis were excluded from the study. Results: Forty nine patients were included in the study. 27 (55%) patients were male and 22 (45%) were female; the age ranges from 23 years to 70 years with the median age 46 years. The main presenting symptoms were bleeding per rectum and tenesmus, Stage II 18 patients (36.7%), stage III 31 patients (63.3%). Complete clinical and pathological response in 3 patients (6%), and complete clinical response with only microscopically residual carcinoma in 20 patients (41%), partial response in 18 patients (36.7%), and no significant response in 8 patients (16%) 7 from 8 were mucoid carcinoma. Low anterior resection (LAR) in 22 patients (44.9%), Hartman’s procedure in 4 patients (8.1%), Coloanal pull-through (COP) was done in 19 patients (38.9%) and perineal colostomy in 4 patients (8.1%). For patients with colo-anal pull-through technique complete dehiscent and retraction observed in 2 cases, Major leakage in one case, stenosis in 4 cases. Conclusion: There is tendency of colorectal cancers to affect younger groups. Most patients presented in advanced stage. Neadjuvant chemo radiation is an excellent tool in sphincter saving surgery. Coloanal pull-through technique is not a widely spread technique for low rectal cancer with good oncological safety and acceptable functional outcome.

Keywords

Coloanal Pull-Through; Colo Rectal Cancer; Neoadjuvant Chemoradiation; Low Anterior Resection

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	R. P. Billingham, “Conservative Treatment of Rectal Cancer. Extending the Indications,” Cancer, Vol. 70, No. 5, 1992, pp. 1355-1363. doi:10.1002/1097-0142(19920901)70:3+<1355::AID-CNCR282070 1525 >3.0.CO; 2-9
[2]	L. D. MacDonald, “The Health of Rectal Cancer Patients in the Community,” European Journal of Surgical Oncology, Vol. 11, No. 3, 1985, p. 235.
[3]	A. Abdelsalem and Y. A. K. Ismail, “Preoperative Radiochemotherapy in Locally Advanced Rectal Cancer,” Journal of the Egyptian National Cancer Institute, Vol. 13, No. 2, 2008, pp. 101-108.
[4]	C. V. Allen, “A Pilot Study on Preoperative Irradiation of Rectosigmoid Carcinoma,” American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine, Vol. 114, No. 3, 1972, pp. 504-508. doi:10.2214/ajr.114.3.504
[5]	J. A. Martenson Jr., et al., “Radiation Therapy Quality Control in a Clinical Trial of Adjuvant Postoperative Treatment for Rectal Cancer,” International Journal of Radiation Oncology Biology Physics, Vol. 32, No. 1, 1995, pp. 51-55. doi:10.1016/0360-3016(95)00526-5
[6]	J. Papillon, et al., “Role of Preoperative Radiotherapy in Preservation of the Anal Sphincter in Cancer of the Lower Rectum,” Bulletin du Cancer, Vol. 77, No. 1, 1990, pp. 15-21.
[7]	G. Marks, M. Mohiuddin and L. Masoni, “The Reality of Radical Sphincter Preservation Surgery for Cancer of the Distal 3 cm of Rectum Following High-Dose Radiation,” International Journal of Radiation Oncology Biology Physics, Vol. 27, No. 4, 1993, pp. 779-783. doi:10.1016/0360-3016(93)90449-6
[8]	P. Rouanet, “Sphincter Conservation and Cancer of the Lower Rectum: Argument for a Multicenter Prospective Study for Conservation of the Sphincter after Irradiation,” Bulletin du Cancer, Vol. 85, No. 4, 1998, pp. 328-332.
[9]	R. J. Heald, “Recurrence and Survival after Total Mesorectal Excision for Rectal Cancer,” Lancet Oncology, Vol. 1, No. 8496, 1986, pp. 1479-1482.
[10]	W. S. Tan, et al., “Meta-Analysis of Defunctioning Stomas in Low Anterior Resection for Rectal Cancer,” British Journal of Surgery, Vol. 96, No. 5, 2009, pp. 462-472. doi:10.1002/bjs.6594
[11]	Y. S. Yeh, et al., “Transanal Inside-Out Rectal Resection for Ultra-Low Rectal Cancer,” Journal of Investigative Surgery, Vol. 25, No. 6, 2012, pp. 375-380. doi:10.3109/08941939.2012.655369
[12]	O. Dahl, et al., “Low-Dose Preoperative Radiation Postpones Recurrences in Operable Rectal Cancer. Results of a Randomized Multicenter Trial in Western Norway,” Bulletin du Cancer, Vol. 66, No. 11, pp. 2286-2294. doi:10.1002/1097-0142(19901201)66:11<2286::AID-CNCR2820661106>3.0.CO;2-T
[13]	L. Pahlman, “Preor Postoperative Radiotherapy in Rectal and Rectosigmoid Carcinoma. Report from a Randomized Multicenter Trial,” Annals of Surgical Oncology, Vol. 211, No. 2, 1990, pp. 187-195. doi:10.1097/00000658-199002000-00011
[14]	E. Rullier, et al., “Preoperative Radiochemotherapy and Sphincter-Saving Resection for T3 Carcinomas of the Lower Third of the Rectum,” Annals of Surgery, Vol. 234, No. 5, 2001, pp. 633-640. doi:10.1097/00000658-200111000-00008
[15]	C. Berger, et al., “Preoperative Radiotherapy (RT) for Rectal Cancer: Predictive Factors of Tumor Downstaging and Residual Tumor Cell Density (RTCD): Prognostic Implications,” International Journal of Radiation Oncology Biology Physics, Vol. 37, No. 3, 1997, pp. 619-627. doi:10.1016/S0360-3016(96)00577-9
[16]	M. C. Kaminsky-Forrett, et al., “Prognostic Implications of Dowstaging Following Preoperative Radiation Therapy for Operable T3-T4 Rectal Cancer,” International Journal of Radiation Oncology Biology Physics, Vol. 42, 1998, pp. 935-941. doi:10.1016/S0360-3016(98)00345-9
[17]	T. A. Rich, J. A. Ajani, et al., “Preoperative Infusional Chemoradiation Therapy for Stage T3 Rectal Cancer,” International Journal of Radiation Oncology Biology Physics, Vol. 32, 1995, pp. 1025-1029. doi:10.1016/0360-3016(95)00020-Y
[18]	V. Valentini, N. Cellini, et al., “Preoperative Chemoradiation for Extraperitoneal T3 Rectal Cancer: Acute Toxicity, Tumor Response, and Sphincter Preservation,” International Journal of Radiation Oncology Biology Physics, Vol. 40, 1998, pp. 1067-1075.
[19]	N. A. Janjan, J. Abbruzzese, et al., “Tumor Downstaging and Sphincter Preservation with Preoperative Chemoradiation in Locally Advanced Rectal Cancer: The M. D. Anderson Cancer Center Experience,” International Journal of Radiation Oncology Biology Physics, Vol. 44, 1999, pp. 1027-1038. doi:10.1016/S0360-3016(99)00099-1
[20]	A. S. Miller, et al., “Factors That Influence Functional Outcome after Coloanal Anastomosis for Carcinoma of the Rectum,” British Journal of Surgery, Vol. 82, No. 10, 1995, pp. 1327-1330. doi:10.1002/bjs.1800821010
[21]	D. Benchimol, et al., “Oncological and Functional Results of Direct Colo-Anal Anastomosis after Total Resection of the Rectum for Cancer,” Annales De Chirurgie, Vol. 48, No. 7, 1994, pp. 596-603.
[22]	B. Bittorf, et al., “Functional Outcome after Intersphincteric Resection of the Rectum with Coloanal Anastomosis in Low Rectal Cancer,” European Journal of Surgical Oncology, Vol. 30, No. 3, 2004, pp. 260-265. doi:10.1016/j.ejso.2003.11.011
[23]	A. G. Parks and J. P. Percy, “Resection and Sutured ColoAnal Anastomosis for Rectal Carcinoma,” British Journal of Surgery, Vol. 69, No. 6, 1982, pp. 301-304. doi:10.1002/bjs.1800690602
[24]	V. Schumpelick and J. Braun, “Intersphincteric Rectum Resection with Radical Mesorectum Excision and ColoAnal Anastomosis,” Chirurg, Vol. 67, No. 2, 1996, pp. 110-120.
[25]	A. Kohler, et al., “Long-Term Results of Low Anterior Resection with Intersphincteric Anastomosis in Carcinoma of the Lower One-Third of the Rectum: Analysis of 31 Patients,” Diseases of the Colon & Rectum, Vol. 43, No. 6, 2000, pp. 843-850. doi:10.1007/BF02238025
[26]	P. M. Sagar and J. H. Pemberton, “Surgical Management of Locally Recurrent Rectal Cancer,” British Journal of Surgery, Vol. 83, No. 3, 1996, pp. 293-304. doi:10.1002/bjs.1800830305
[27]	P. Luna-Perez, et al., “Anal Sphincter Preservation in Locally Advanced Low Rectal Adenocarcinoma after Preoperative Chemoradiation Therapy and Coloanal Anastomosis,” Journal of Surgical Oncology, Vol. 82, No. 1, 2003, pp. 3-9. doi:10.1002/jso.10185
[28]	G. Eichhoff, “Shortand Long-Term Results of HandSewn Coloanal Anastomosis Performed as a Salvage Procedure after Rectal Resection,” The Internet Journal of Surgery, Vol. 18, No. 1, 2009, pp. 1528-8242. doi:10.1007/BF02554801
[29]	H. K. Antonsen, “Early Complications after Low Anterior Resection for Rectal Cancer Using the EEA Stapling Device. A Prospective Trial,” Diseases of the Colon & Rectum, Vol. 30, 1987, pp. 579-583.
[30]	S. Athanasiadis, “Surgical Treatment of Radiation-Induced Rectovaginal Fistulas by the Continence Resection Procedure,” Zentralblatt fur Chirurgie, Vol. 107, 1982, pp. 1160-1168.
[31]	M. P. Nowacki, “Ten Years of Experience with Parks’ Coloanal Sleeve Anastomosis for the Treatment of PostIrradiation Rectovaginal Fistula,” European Journal of Surgical Oncology, Vol. 17, No. 6, 1991, pp. 563-566.
[32]	R. Schiessel, et al., “Intersphincteric Resection for Low Rectal Tumours,” British Journal of Surgery, Vol. 81, No. 9, 1994, pp. 1376-1378. doi:10.1002/bjs.1800810944
[33]	E. Rullier, et al., “Laparoscopic Intersphincteric Resection with Coloplasty and Coloanal Anastomosis for Mid and Low Rectal Cancer,” British Journal of Surgery, Vol. 90, No. 4, 2003, pp. 445-451. doi:10.1002/bjs.4052
[34]	S. H. Baik, et al., “Hand-Sewn Coloanal Anastomosis for Distal Rectal Cancer: Long-Term Clinical Outcomes,” Journal of Gastrointestinal Surgery, Vol. 9, No. 6, 2005, pp. 775-780. doi:10.1016/ j.gassur.2005.03.003
[35]	M. R. Keighley and D. Matheson, “Functional Results of Rectal Excision and Endo-Anal Anastomosis,” British Journal of Surgery, Vol. 67, No. 10, 1980, pp. 757-761. doi:10.1002/bjs.1800671021
[36]	P. Rouanet, et al., “Conservative Surgery for Low Rectal Carcinoma after High-Dose Radiation. Functional and Oncologic Results,” Annals of Surgery, Vol. 221, No. 1, 1995, pp. 67-73. doi:10.1097/ 00000658-199501000-00008
[37]	R. Schiessel, M. Wunderlich and R. Waneck, “Results of Colo-Anal Anastomosis in Deep-Seated Tumors of the Rectum,” Chirurg, Vol. 57, No. 12, 1986, pp. 792-796.
[38]	P. G. Horgan, et al., “Effect of Anterior Resection on Anal Sphincter Function,” British Journal of Surgery, Vol. 76, No. 8, 1989, pp. 783-786. doi:10.1002/bjs.1800760805