The importance of rectal washout for the oncological outcome after Hartmann’s procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry

Jörgren, Fredrik; Arnadottir, H.; Lindmark, Gunilla

doi:10.1007/s10151-017-1637-5

Cited by 13 publications

(12 citation statements)

References 35 publications

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“…Hartmann's procedure has previously been associated with low major complication and mortality rates, and is often reserved for frailer patients. However, more recently the complication profile appears to have been quite high, with the frequency of pelvic abscesses ranging from 12 to 33 per cent, further increasing the risk of pelvic seeding after leakage of intraluminal contents from the distal rectal remnant. These findings perhaps point towards Hartmann's being a surrogate marker of, for example, fitness or frailty of a patient, but it is not possible to conclude this from the data in the present study.…”

Section: Discussionmentioning

confidence: 66%

“…Hartmann's procedure may be an independent predictor of local recurrence owing to the risk of viable exfoliated cancer cells, capable of implanting, being present within the bowel lumen; these become a potential source of local recurrence due to incorporation into the staple line at the rectal stump. Hartmann's procedure has previously been associated with low major complication and mortality rates, and is often reserved for frailer patients. However, more recently the complication profile appears to have been quite high, with the frequency of pelvic abscesses ranging from 12 to 33 per cent, further increasing the risk of pelvic seeding after leakage of intraluminal contents from the distal rectal remnant.…”

Section: Discussionmentioning

confidence: 99%

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Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

Peacock

Waters

Bressel

et al. 2019

British Journal of Surgery

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Background: Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers.Methods: Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure. Results: Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82⋅8 per cent (298 patients) and the local recurrence rate was 12⋅5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4⋅49, 95 per cent c.i. 1⋅99 to 10⋅14; P = 0⋅002) and lymphovascular invasion (HR 2⋅02, 1⋅08 to 3⋅77; P = 0⋅032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease.Conclusion: This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.

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Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

Peacock

Waters

Bressel

et al. 2019

British Journal of Surgery

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“…The data indicated that the risk of LR was higher after perforation during APR compared with the other abdominal resection procedures, but the limited number of events in the cohort did not allow further subgroup analysis. However, as one indication for HP in rectal cancer surgery is adverse intraoperative events making anastomosis inappropriate, some of the perforations registered after HP might have been a consequence of incidental perforation when the primary intention was AR 22 . Unfortunately, the SCRCR does not contain data on this issue.…”

Section: Discussionmentioning

confidence: 99%

Impact of rectal perforation on recurrence during rectal cancer surgery in a national population registry

Jörgren

Lydrup

Buchwald

2020

British Journal of Surgery

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Background: Incidental perforation in rectal cancer surgery is considered a risk factor for poorer oncological outcome. Most studies emanate from the era before total mesorectal excision when staging, neoadjuvant treatment and surgical technique were suboptimal. This study assessed the impact of incidental perforation on oncological outcome in a cohort of patients with optimized management. Methods: Data from the Swedish Colorectal Cancer Registry for patients undergoing R0 abdominal surgery for TNM stage I-III rectal cancer between 2007 and 2012, with 5-year follow-up, were analysed. Multivariable analysis was performed. Results: In total, 6176 patients were analysed (208 with and 5968 without perforation). The local recurrence rate was increased after perforation (7⋅2 per cent (15 of 208) versus 3⋅2 per cent (188 of 5968); P = 0⋅001), but there were no differences in rates of distant metastasis (16⋅3 per cent (34 of 208) versus 19⋅8 per cent (1183 of 5968); P = 0⋅215) and overall recurrence (20⋅7 per cent (43 of 208) versus 21⋅0 per cent (1256 of 5968); P = 0⋅897). The 5-year overall survival rate was lower after perforation (66⋅4 versus 75⋅5 per cent; P = 0⋅002), but the 5-year relative survival rate was no different (79⋅9 versus 88⋅2 per cent; P = 0⋅083). In multivariable analysis, perforation was a risk factor for local recurrence (hazard ratio 2⋅10, 95 per cent c.i. 1⋅19 to 3⋅72; P = 0⋅011), but not for the other outcomes. Conclusion: Incidental perforation remains a significant risk factor for LR, even with optimized management of rectal cancer. This must be considered when discussing adjuvant treatment and follow-up.

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“…By contrast, several studies have demonstrated no clear efficacy of rectal washout in preventing local recurrence [6,[17][18][19][20]. For instance, Terzi et al conducted a prospective clinical study on 96 patients with colorectal cancer undergoing anterior resection and concluded that rectal washout did not decrease the rate of local recurrence [6].…”

Section: Discussionmentioning

confidence: 99%

Is Intraluminal Washout Necessary for Patients with Sigmoid Colon Cancer to Eliminate Exfoliated Cancer Cells as in Patients with Rectal Cancer? A Pilot Study at a Single Institute

Shimizu

Sudo

Furuya

et al. 2020

J Anus Rectum Colon

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Objectives: Rectal stump washout has been widely performed to prevent the implantation of exfoliated cancer cells (ECCs) in patients with rectal cancer. However, it remains unclear whether intraluminal washout before transection is required in patients with sigmoid colon cancer. Therefore, this pilot study was conducted to elucidate the necessity of intraluminal washout for sigmoid colon cancer patients in comparison with rectal cancer patients by cytological assessments. Methods: A total of 16 patients with sigmoid colon cancer and 24 patients with rectal cancer who underwent sigmoidectomy or anterior resection with anastomosis using double-stapling technique were enrolled. A transanal washout sample was collected before washout and after irrigation with 500 and 1,000 mL of saline. Cytological assessments were conducted according to the Papanicolaou classification, and class IV and V cells were defined as malignant. Results: Before washout, exfoliated cancer cells were found in 15 of 24 (62.5%) patients with rectal cancer and in 1 of 16 (6.2%) patients with sigmoid colon cancer (p < 0.001). Distal-free margin from the tumor was significantly shorter in patients with cancer cells (p = 0.002), and the length of the distal-free margin was significantly associated with the tumor location. After irrigation with 500 and 1,000 mL of saline, no cancer cell was found in all patients with sigmoid colon cancer, whereas ECCs were still found in five patients with rectal cancer (20.8%). Conclusions: Intraluminal washout with 1,000 mL may be sufficient for sigmoid colon cancer patients with longer distal-free margin. A large-scale, randomized controlled study is necessary to confirm these results.

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The importance of rectal washout for the oncological outcome after Hartmann’s procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry

Cited by 13 publications

References 35 publications

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

Impact of rectal perforation on recurrence during rectal cancer surgery in a national population registry

Is Intraluminal Washout Necessary for Patients with Sigmoid Colon Cancer to Eliminate Exfoliated Cancer Cells as in Patients with Rectal Cancer? A Pilot Study at a Single Institute

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