Abstract
Background
Variabilities of both oncologic and functional outcomes are major problems after rectal cancer treatment. Standardized techniques might produce more consistent surgical quality. This study reports outcomes during a 20-year period resulting from a systematically applied surgical approach.
Methods
Between 1990 and 2010, 368 rectal cancer patients, treated with total mesorectal excision conducted in a standardized, stepwise approach, were prospectively entered into a database. Influence of time period, surgeon, tumor and anastomotic height, and resection type was evaluated with multivariable regression analyses adjusting for age, disease stage, diversion, and (neo)adjuvant treatment. Function outcome questionnaires were sent to 50 patients at least 5 years after surgery.
Results
Five-year overall survival was 76.4 %. Local and distant recurrence rates were 5.2 % and 22.1 %. Anastomotic leakage occurred in 5.4 % of patients treated with low anterior resection (n = 259). Time period, surgeon, tumor and anastomotic height, diversion, and abdominoperineal resection were not independent risk factors for any of these outcome measures. Both preoperative and postoperative radiotherapy were independently associated with increased risk of metastases (P = 0.035, hazard ratio (HR) = 3.04; and P = 0.029, HR = 3.59). Function questionnaires were completed by 38 of 50 patients (76 %). One of 13 nonirradiated patients reported mild fecal incontinence compared with 20 of 25 irradiated patients reporting mostly moderate-severe incontinence (P < 0.001).
Conclusions
Systematically applied surgical dissection results consistently in excellent oncologic outcomes with enhanced function outcomes. The findings suggest that in the presence of highly disciplined surgery, radiotherapy might make a smaller contribution to oncologic outcome, while leading to serious adverse effects.
Similar content being viewed by others
References
Heald RJ. A new approach to rectal cancer. Br J Hosp Med. 1979;22(3):277–81.
Hermanek P, Hermanek PJ. Role of the surgeon as a variable in the treatment of rectal cancer. Semin Surg Oncol. 2000;19(4):329–35.
Martling A, Cedermark B, Johansson H, Rutqvist LE, Holm T. The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg. 2002;89(8):1008–13.
Mack LA, Temple WJ. Education is the key to quality of surgery for rectal cancer. Eur J Surg Oncol. 2005;31(6):636–44.
Sant M, Allemani C, Santaquilani M, Knijn A, Marchesi F, Capocaccia R. EUROCARE-4. Survival of cancer patients diagnosed in 1995–1999. Results and commentary. Eur J Cancer. 2009;45(6):931–91.
Giacomantonio CA, Temple WJ. Quality of cancer surgery: challenges and controversies. Surg Oncol Clin N Am. 2000;9(1):51–60, vii.
Hermanek P, Wiebelt H, Staimmer D, Riedl S. Prognostic factors of rectum carcinoma–experience of the german multicentre study SGCRC. German Study Group Colo-Rectal Carcinoma. Tumori. 1995;81(3 Suppl):60–4.
Leonard D, Penninckx F, Fieuws S, Jouret-Mourin A, Sempoux C, Jehaes C, Van Eycken E. Factors predicting the quality of total mesorectal excision for rectal cancer. Ann Surg. 2010;252(6):982–8.
Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23(36):9257–64.
Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, Dixon MF, Mapstone NP, Sebag-Montefiore D, Scott N, Johnston D, Sagar P, Finan P, Quirke P. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242(1):74–82.
Pahlman L, Bohe M, Cedermark B, Dahlberg M, Lindmark G, Sjodahl R, Ojerskog B, Damber L, Johansson R. The Swedish Rectal Cancer Registry. Br J Surg. 2007;94(10):1285–92.
Alberts JC, Parvaiz A, Moran BJ. Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection. Colorectal Dis. 2003;5(5):478–82.
Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD. Postoperative complications following surgery for rectal cancer. Ann Surg. 2010;251(5):807–18.
Peeters KC, van de Velde CJ, Leer JW, Martijn H, Junggeburt JM, Kranenbarg EK, Steup WH, Wiggers T, Rutten HJ, Marijnen CA. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients–a Dutch Colorectal Cancer Group study. J Clin Oncol. 2005;23(25):6199–206.
Lange MM, den Dulk M, Bossema ER, Maas CP, Peeters KC, Rutten HJ, Klein KE, Marijnen CA, van de Velde CJ. Risk factors for faecal incontinence after rectal cancer treatment. Br J Surg. 2007;94(10):1278–84.
Bretagnol F, Troubat H, Laurent C, Zerbib F, Saric J, Rullier E. Long-term functional results after sphincter-saving resection for rectal cancer. Gastroenterol Clin Biol. 2004;28(2):155–9.
Wallner C, Lange MM, Bonsing BA, Maas CP, Wallace CN, Dabhoiwala NF, Rutten HJ, Lamers WH, DeRuiter MC, van de Velde CJ. The role of damage to the levator ani nerve during rectal cancer surgery in the development of fecal and urinary incontinence. J Clin Oncol. 2008;26:4466–72.
Lindsetmo RO, Delaney CP. A standardized technique for laparoscopic rectal resection. J Gastrointest Surg. 2009;13(11):2059–63.
Enker WE. Potency, cure, and local control in the operative treatment of rectal cancer. Arch Surg. 1992;127(12):1396–401.
Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg. 1995;181(4):335–46.
Enker WE. Total mesorectal excision–the new golden standard of surgery for rectal cancer. Ann Med. 1997;29(2):127–33.
Engstrom PF, Arnoletti JP, Benson AB III, Chen YJ, Choti MA, Cooper HS, Covey A, Dilawari RA, Early DS, Enzinger PC, Fakih MG, Fleshman J Jr, Fuchs C, Grem JL, Kiel K, Knol JA, Leong LA, Lin E, Mulcahy MF, Rao S, Ryan DP, Saltz L, Shibata D, Skibber JM, Sofocleous C, Thomas J, Venook AP, Willett C. NCCN Clinical Practice Guidelines in Oncology: Rectal cancer. J Natl Compr Canc Netw. 2009;7(8):838–81.
Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the rectum and the rectosacral fascia. Surg Radiol Anat. 1991;13(1):17–22.
Hida J, Yasutomi M, Maruyama T, Fujimoto K, Uchida T, Okuno K. Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision. J Am Coll Surg. 1997;184(6):584–8.
Enker WE. Cancer of the rectum: primary and adjuvant therapy. Fazio VW (ed) Current therapy in colon and rectal cancer. Philadelphia: Decker, B.C., 1990;120–30.
Adam IJ, Mohamdee MO, Martin IG, Scott N, Finan PJ, Johnston D, Dixon MF, Quirke P. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344(8924):707–11.
National workgroup for gastrointestinal tumours. Dutch National Guideline for Rectal Cancer (Version 2.0). www oncoline nl 2008.
Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet. 2001;358(9290):1291–304.
Figueredo A, Zuraw L, Wong RK, Agboola O, Rumble RB, Tandan V. The use of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer: a practice guideline. BMC Med. 2003;1:1.
Roh MS, Colangelo LH, O’Connell MJ, Yothers G, Deutsch M, Allegra CJ, Kahlenberg MS, Baez-Diaz L, Ursiny CS, Petrelli NJ, Wolmark N. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol. 2009;27(31):5124–30.
Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351(17):1731–40.
Mathis KL, Larson DW, Dozois EJ, Cima RR, Huebner M, Haddock MG, Nelson H, Pemberton JH. Outcomes following surgery without radiotherapy for rectal cancer. Br J Surg. 2012;99:137–143.
Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, Sebag-Montefiore DJ, Tekkis P, Brown G. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg 2011;253(4):711–9.
Fisher B, Wolmark N, Rockette H, Redmond C, Deutsch M, Wickerham DL, Fisher ER, Caplan R, Jones J, Lerner H. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP Protocol R-01. J Natl Cancer Inst. 1988;80(1):21–9.
Inoue Y, Ojima E, Watanabe H, Hiro J, Toiyama Y, Kobayashi M, Miki C, Kusunoki M. Does preoperative chemo-radiotherapy enhance the expression of vascular endothelial growth factor in patients with rectal cancer? Oncol Rep. 2007;18(2):369–75.
Park JS, Qiao L, Su ZZ, Hinman D, Willoughby K, McKinstry R, Yacoub A, Duigou GJ, Young CS, Grant S, Hagan MP, Ellis E, Fisher PB, Dent P. Ionizing radiation modulates vascular endothelial growth factor (VEGF) expression through multiple mitogen activated protein kinase dependent pathways. Oncogene. 2001;20(25):3266–80.
Nozue M, Isaka N, Fukao K. Over-expression of vascular endothelial growth factor after preoperative radiation therapy for rectal cancer. Oncol Rep. 2001;8(6):1247–9.
Pollack J, Holm T, Cedermark B, Altman D, Holmstrom B, Glimelius B, Mellgren A. Late adverse effects of short-course preoperative radiotherapy in rectal cancer. Br J Surg. 2006;93(12):1519–25.
Marijnen CA, Kapiteijn E, van de Velde CJ, Martijn H, Steup WH, Wiggers T, Kranenbarg EK, Leer JW. Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol. 2002;20(3):817–25.
Vuong T, Devic S, Podgorsak E. High-dose rate endorectal brachytherapy as a neoadjuvant treatment for patients with resectable rectal cancer. Clin Oncol (R Coll Radiol). 2007;19(9):701–5.
Acknowledgments
This work has been approved by the Institutional Review Board of Beth Israel Medical Center and was supported by the Dorothy and Lawrence Kryger Surgical Oncology Research Fund.
Conflicts of interest
None
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lange, M.M., Martz, J.E., Ramdeen, B. et al. Long-term Results of Rectal Cancer Surgery with a Systematical Operative Approach. Ann Surg Oncol 20, 1806–1815 (2013). https://doi.org/10.1245/s10434-012-2832-2
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-012-2832-2