Safety and Efficacy of Low Anterior Resection for Rectal Cancer

Enker, Warren E.; Merchant, Nipun B.; Cohen, Alfred M.; Lanouette, Nicole M.; Swallow, Carol J.; Guillem, José G.; Paty, Philip B.; Minsky, Bruce D.; Weyrauch, Katherine; Quan, Stuart H. Q.

doi:10.1097/00000658-199910000-00010

Cited by 271 publications

(167 citation statements)

References 29 publications

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“…However, we did not find relevant differences in the incidence of intraabdominal abscesses (4.7%) and anastomotic dehiscence (4.2%). These results are in agreement with those described by Enker et al, 36 who concluded that preoperative chemoradiotherapy increases the time of surgery, blood loss, and formation of pelvic abscesses but does not increase anastomotic dehiscence or duration of hospitalization.…”

Section: Discussionsupporting

confidence: 93%

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

et al. 2007

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Background: The impact of neoadjuvant treatment and their subsequent early complications in the treatment of rectal cancer has not been adequately assessed. The aim of this prospective study was to evaluate early postoperative morbidity and mortality among patients with rectal cancer treated with adjuvant radiotherapy and chemotherapy followed by surgery, compared with patients treated with surgery alone. We also identified independent risk factors associated with early major complications. Methods: Between 1995 and 2004, 273 consecutive patients underwent treatment for rectal cancer. A total of 170 patients (group A) received preoperative radiotherapy with a total of 45-50.4 Gy (180 cGy per day) and 5-fluorouracil-based chemotherapy, followed by surgery; 103 patients (group B) were treated with surgery alone. Dependent variables related to patients, treatment, radiotherapy, and tumor were analyzed. Results: Both groups were similar with regard to age, sex, body mass index, American Society of Anesthesiologists (ASA) score, and tumor location but not for ileostomy (27% in group A vs. 6.8% in group B). The number of complications was similar in both groups (43.1% in group A vs. 44.6% in group B). No differences in wound infection (8.2% vs. 7.8%), intraabdominal abscess (4.7% vs. 4.9%), anastomotic dehiscence (4.2% vs. 3.8%), postoperative hemorrhage (3.5% vs. 3.9%), urinary complications (6.5% vs. 4.9%), paralytic ileus (8.9% vs. 9.7%), or general complications (7.1% vs. 9.6%) were found. The global mortality in the first 30 days after surgery was .7%. An ASA score of III-IV and surgery duration longer than 3 hours were identified as independent prognostic factors for early complications. Conclusions: Preoperative chemoradiation in patients with rectal cancer treated with surgery is not associated with a higher incidence of early postoperative complications. The patient~s preoperative clinical condition and lengthy surgery time are prognostic factors for early complications.

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Section: Discussionsupporting

confidence: 93%

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

et al. 2007

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“…3,4 Intact removal of the entire mesorectum (total mesorectal excision or TME) in cancers of the mid or lower third of the rectum was pioneered by Heald and has resulted in local recurrence rates lower than 5-10%. [5][6][7] Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce local recurrence rates. Neoadjuvant radiotherapy (RT) has been shown to significantly decrease local recurrence rate and improve survival provided a biologically equivalent dose (BED) of at least 30 gray (Gy) is administered.…”

mentioning

confidence: 99%

Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer: A systematic review and meta‐analysis

Ceelen

Fierens

Nieuwenhove

et al. 2009

Intl Journal of Cancer

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Combining chemotherapy with preoperative radiotherapy (RT) has a sound radiobiological rationale. We performed a systematic review and meta-analysis of trials comparing preoperative RT with preoperative chemoradiation (CRT) in rectal cancer patients. The Cochrane Central Register of Controlled Trials, Web of Science, Embase and Medline (Pubmed) were searched from 1975 until June 2007. Dichotomous parameters were summarized using the odds ratio while time to event data were analyzed using the pooled hazard ratio for death. From the primary search result of 324 trials, 4 relevant randomized trials were identified. The addition of chemotherapy significantly increased grade III and IV acute toxicity (p 5 0.002) while no differences were observed in postoperative morbidity or mortality. Preoperative CRT significantly increased the rate of pathological complete response (p < 0.001) although this did not translate into a higher sphincter preservation rate (p 5 0.29). The local recurrence rate was significantly lower in the CRT group (p < 0.001). No statistically significant differences were observed in disease free survival (p 5 0.89) or overall survival (p 5 0.79). Compared to preoperative RT alone, preoperative CRT improves local control in rectal cancer but is associated with a more pronounced treatment related toxicity. The addition of chemotherapy does not benefit sphincter preservation rate or long-term survival. Future trials should address improvements in the rate of distant metastasis and overall survival by incorporating more active chemotherapy. ' UICCKey words: rectal cancer; radiotherapy; surgery The incidence of fatal cases of colorectal cancer in Europe exceeds 200,000 per year. 1 Because of the specific anatomy and biology of rectal cancer, surgery alone historically has been associated with local recurrence in up to 1 in 4 patients. 2 Locally recurrent disease is usually incurable, causes important morbidity and suffering and gives rise to systemic metastases. In the last few decades, improvements in surgical technique have dramatically lowered the incidence of locally recurrent disease. Careful pathological studies have clearly demonstrated that the major cause of local recurrence is the persistence of tumor foci within the mesorectum. 3,4 Intact removal of the entire mesorectum (total mesorectal excision or TME) in cancers of the mid or lower third of the rectum was pioneered by Heald and has resulted in local recurrence rates lower than 5-10%. [5][6][7] Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce local recurrence rates. Neoadjuvant radiotherapy (RT) has been shown to significantly decrease local recurrence rate and improve survival provided a biologically equivalent dose (BED) of at least 30 gray (Gy) is administered. 8 The advantages of preoperative over postoperative RT include enhanced effectiveness in well-oxygenated tissue, downstaging of advanced tumors and better treatment compliance. 9 The theoretical ...

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“…About 60 -81% of all patients on combined modality treatment will have at least a Grade 3 toxicity during therapy [34]. In addition, anorectal outcome such as number of bowel movements per day, fecal continence as well as sexual function such as potency have been shown to be worse in patients who received radiation [35][36][37][38][39]. Interestingly, overall quality of life was not statistically different between the patients who received radiation and patients who did not, as addressed in follow up of the Dutch TME trial [40].…”

Section: Adjuvant Pelvic Radiation Decreases Lo-cal Recurrencementioning

confidence: 99%

The Changing Role of Radiation in the Post-TME ERA of Rectal Cancer

Lai¹,

Thomas²

2010

CCTR

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Total mesorectal excision (TME) for rectal cancer is now considered standard in the surgical treatment of rectal cancer. The application of this technique has resulted in a pooled pelvic recurrence rate of approximately 7%. Preoperative and postoperative radiation further decreases the local regional recurrence (LRR) rate in patients with rectal cancer but the reduction in risk is counterbalanced by increased short and long term toxicity. Lower LRR rates have not uniformly translated into more favorable overall survival. In addition, advances in imaging have resulted in more accurate pretreatment staging and have improved the ability to stratify patients based on risk of recurrence. Given low pelvic recurrence rates after TME-based surgery alone, the risks and toxicities of pelvic radiation, and superior imaging to select high risk patients, radiation may not be requisite in the treatment of all rectal cancer patients. In this review, we discuss the current status of radiation and LRR rates in rectal cancer after definitive surgical resection with respect to specific subsites and stages of disease, examine the impact of imaging in the selection of patients for radiation, and raise the possibility that predictive biomarkers may help to identify patients who may not require pelvic radiation.

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Safety and Efficacy of Low Anterior Resection for Rectal Cancer

Cited by 271 publications

References 29 publications

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer: A systematic review and meta‐analysis

The Changing Role of Radiation in the Post-TME ERA of Rectal Cancer

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