In the recent 2 decennaries, betterments have been achieved in the results of rectal malignant neoplastic disease surgery with the progresss in surgical techniques every bit good as accessory therapy. Abdominoperineal resection, the old gold criterion intervention of rectal malignant neoplastic disease, has been regarded as unneeded in most patients with rectal malignant neoplastic disease and more patients can now be treated with sphincter-saving surgery. The increased apprehension of the spread of the disease has contributed significantly to this alteration. Distal mural spread of the disease was shown to be seldom more than 2 centimeter, [ 1 ] and the allowance of a close distal border has led to an increased incidence of sphincter-saving operations. Furthermore, safe inosculation at the distal rectum or the anal canal has been made possible by the progresss of mechanical stapling devices and the development of the dual stapling technique [ 2, 3 ] .
Local return has ever been a formidable job following rectal malignant neoplastic disease surgery. Conventional rectal mobilisation by blunt dissection has been associated with a high local return rate [ 4-6 ] . The importance of the complete remotion of the lymphovascular tissue environing the rectum and a free circumferential border has been recognized in the direction of rectal malignant neoplastic disease [ 7 ] . By crisp punctilious perimesorectal dissection and entire mesorectal deletion ( TME ) , Heald et al [ 8 ] and Enker et al [ 9 ] have reported low local return rates in patients with rectal malignant neoplastic disease. However, everyday TME in rectal malignant neoplastic disease at all degrees has been challenged in position of the increased morbidity associated with it. The anastomotic escape rates are high in series of patients with TME [ 10 ] . Furthermore, the intestine map will besides be adversely affected with a low colorectal or coloanal inosculation [ 11 ] . Therefore, selective TME harmonizing to the degree of tumour appears to be a sensible attack. This survey examines the mortality, morbidity, local failure rate, and endurance following anterior resection with crisp perimesorectal dissection for rectal malignant neoplastic disease with selective TME for mid and distal rectal malignant neoplastic disease in a high volume centre. Hazard factors for anastomotic escape, local return, and endurance are analyzed with univariate and multivariate analysis.
Material and Methods
During the 7-year period from January 2003 to November 2010, 298 patients underwent resection of primary rectal and rectosigmoid malignant neoplastic disease in the Department of Surgery, B.P.K.I.H.S, Dharan, Nepal. This survey included all patients who underwent anterior resection. Patients with abdominoperineal resection ( n = 79 ) , Hartmann ‘s operation ( n = 24 ) , and local deletion ( n = 21 ) were excluded. All the patients had histologically proven glandular cancer of the rectum or rectosigmoid. Datas on the patients ‘ demographics, comorbidities, operative inside informations, postoperative mortality and morbidity, histological consequences, and long-run results were collected prospectively.
During the survey period, the operations were performed by the adviser sawboness. TME, which was defined as the transection of the rectum at the degree of the pelvic floor with the full integral mesorectum, was performed for most patients with mid and distal rectal malignant neoplastic disease. For those tumours at upper rectum or rectosigmoid, transection of the rectum and mesorectum 4 to 5 centimeter below the lower boundary line of the tumour was performed following crisp perimesorectal dissection ( PME ) .
Preoperative intestine readying with polythene ethanediol solution was given the twenty-four hours before surgery except in patients with blockading malignant neoplastic diseases. Prophylactic endovenous antibiotics were given at the initiation of anesthesia. Most of the patients underwent laparotomy through a lower midplane scratch.
Rectal mobilisation was carried out by crisp dissection under the direct vision. The splanchnic pelvic facia together with the mesorectum was kept integral during the class of rectal dissection. Attempts were made to place and continue the hypogastric nervousnesss, pelvic nervus retes during the dissection. In the anterior dissection, the peritoneum was incised 1 to 2 centimeters above the rectouterine or rectovesical pouch. The rectum was mobilized down to the pelvic floor.
In the initial period of the survey, selective proximal recreation was performed. Loop cross colostomy was our preferable manner of proximal recreation. After our analysis on the hazard factors for anastomotic escape, proximal recreation was performed in the bulk of patients with an inosculation within 5 centimeter from the anal brink. A hand-sewn interrupted individual bed colorectal / coloanal inosculation was our preferable manner of reconstructing intestine continuity.
Accessory radiation therapy was non routinely given to patients with phase II or phase III disease. Postoperative chemoradiation was offered merely to those when the local clearance was in uncertainty. Preoperative chemoradiation was given to those with fixed T4 lesions. Chemotherapy based on 5-fluorouracil and leucovorin was offered to patients younger than 75 old ages with phase II or phase III disease.
Patients were followed up at intervals of 2 to 3 months during the first 2 old ages and 4 to 6 months from twelvemonth 3 to twelvemonth 5. Thereafter the patients were seen annually. Follow-up was by clinical history and scrutiny, blood trials, and serum carcinoembryonic antigen. Digital rectal scrutiny was performed at each visit to observe any anastomotic stenosis or local return. If returns were suspected, endoscopic scrutiny and computed imaging ( CT ) scan was performed to find whether salvage surgery could be performed.
Comparison of categorical variables was performed with I‡2 trial or Fisher exact trial when appropriate. Continuous variables were presented as agencies ( standard divergence ) or average values ( scope ) . These variables were compared with Mann-Whitney U trial. Survival was analyzed with the Kaplan Meier method and the factors were compared with the log-rank trial. Multivariate analysis was performed with Cox relative jeopardy theoretical account. P values of less than 0.05 were considered statistically important.
A sum of 298 patients underwent anterior resection for primary rectal or rectosigmoid malignant neoplastic disease during the survey period. There were 163 ( 54.7 % ) work forces and 135 ( 45.3 % ) adult females. The average age was 52.2 A± 15.7 old ages ( scope, 19-80 old ages ) . The average degree of the tumour from the anal brink was 7 centimeter ( scope, 2.5-18 centimeter ) . Surgery with healing purpose was performed in 272 patients ( 91.3 % ) . Twenty-six patients ( 8.7 % ) had alleviative surgery because of unresectable distant metastasis ( n = 19 ) or residuary local disease ( n = 7 ) .
Premorbid medical status was present in 117 patients ( 39.2 % ) and they are shown in Table 1. The bulk of the attendant medical diseases were high blood pressure, ischaemic bosom disease, diabetes, and chronic clogging air passage disease. Eleven patients ( 3.7 % ) had synchronal malignant neoplastic disease in another portion of the colon. Seven of the synchronal tumours were distal to the splenetic flection and the anterior resection could accomplish resection of the synchronal tumours. Four patients had synchronal malignant neoplastic disease at the colon proximal to the splenetic flection and synchronal right colectomy was performed. In another 3 patients, right hemicolectomy was performed for benign lesions of the right colon or appendix.
TABLE1. Comorbidities of patients with anterior resection
Hand-sewn inosculation was performed in all patients. Twenty-one peranal coloanal inosculation was performed for ultra-low malignant neoplastic diseases. The average operative clip was 183 proceedingss ( A± 62 proceedingss ) and the average blood loss was 426 milliliter ( A± 451 milliliter ) . Resection of other variety meats was required in 21 patients ( 7.1 % ) . Partial vesica resection was performed in 5 patients.
Three patients with potentially healing surgery had positive border on histology. One of them underwent abdominoperineal resection and remained good 6 old ages following surgery. The other 2 patients refused farther operation and died of liver metastasis at 24 months and local return at 41 months, severally.
Radiation therapy, normally with chemotherapy, was given to 16 patients ( preoperative, n = 4 ; postoperative, n = 12 ) . One of the patients showed complete response following neoadjuvant chemoradiation. The TNM system was used for presenting and the concluding pathologic phases of the tumours were as follows: 1 phase 0 ( 0.3 % ) , 41 phase I ( 13.8 % ) , 98 phase II ( 32 % ) , 132 phase III ( 44.3 % ) , and 26 phase IV ( 8.7 % ) .
TME was performed in 202 patients ; while in other 96 patients, transection of the rectum and mesorectum ( PME ) was performed above the pelvic floor either because of high rectal malignant neoplastic disease or because of alleviative resection. The differences between operations with and without TME are shown in Table 2. Operationss with TME were associated with longer operative clip, more blood loss, a higher incidence of pore creative activity, and a longer hospital stay. The escape rate was besides significantly higher in the TME group. However, the overall postoperative mortality and morbidity did non demo any important differences between patients with TME and PME.
Table 2. Comparison between patients with and without TME
Eleven patients died in the postoperative period from 1 to 38 yearss after the surgery. The operative mortality was 3.7 % . All these patients had premorbid medical diseases. The causes of decease included myocardial infarction or ischaemia ( n = 3 ) , pneumonia ( n = 4 ) , and sepsis ( n = 4 ) .
A sum of 90 patients ( 30.2 % ) developed intraoperative or postoperative complications. The types of complications are shown in Table 3. Clinical anastomotic escape occurred in 18 patients ( 6.1 % ) . Comparison of hazard factors for anastomotic escape is shown in Table 4. Multivariate analysis showed that the usage of TME ( P & lt ; 0.001, jeopardies ratio [ HR ] , 6.3 ; 95 % CI, 3.4-46.7 ) , the male gender ( P & lt ; 0.02, HR, 2.9 ; 95 % CI, 1.2-7.2 ) , the absence of pore ( P = 0.001, HR, 4.0 ; 95 % CI, 1.8-9.0 ) , and blood loss more than 500 milliliter ( P = 0.02, HR, 2.5 ; 95 % CI, 1.2-5.3 ) were independent factors for a higher incidence of anastomotic escape.
Table 3. Postoperative complications of patients with anterior resection
Table 4. Univariate analysis of hazard factors for anastomotic escape
With the average followup of the lasting patients of 38.7 months ( 2-104 months ) , 32 patients developed local return. The actuarial 2-year and 5-year local return rates were 7.0 % and 10.7 % , severally. These included patients with local return entirely every bit good as those with both local and distant diseases. Analysis of hazard factors for local return is shown in Table 5. On univariate analysis, the advanced phase, resection border of less than 2 centimeter, the presence of perineural invasion, or lymphovascular pervasion were risk factors for local return. In the multivariate analysis, merely the phase of the disease ( P = 0.001, HR, 2.9 ; 95 % CI, 1.6-5.4 ) was independent factors associated with a high incidence of local return.
The 5-year overall endurance and cancer-specific endurance rated were 67.5 % and 75.5 % , severally. The univariate analysis of the hazard factors for the cancer-specific endurance is shown in Table 5. Multivariate analysis showed that the phase of disease, the presence lymphovascular every bit good as perineural pervasion were independent variables associated with hapless disease-specific endurance.
Table 5. Univariate analysis of hazard factors for local return
The optimum intervention of rectal malignant neoplastic disease should maximise sphincter saving with low morbidity and mortality. Furthermore, favorable oncological results in footings of a low local return rate and a high endurance rate are besides of import considerations. The surgical technique plays an of import function to accomplish these short-run and long-run ends. In the recent 2 decennaries, anterior resection with mesorectal deletion has become the optimum intervention of rectal malignant neoplastic disease.
Sharp punctilious dissection to maintain the splanchnic bed of the pelvic facia intact is of import to avoid breach in the mesorectum, which is now considered an of import cause for local return. Heald et al [ 8 ] every bit good as Enker et al [ 9, 13 ] have reported low local return rates utilizing this technique in a ample figure of patients. The usage of crisp perimesorectal dissection and the pattern of “ close shaving ” anterior resection have besides increased the sphincter salvaging rate. Heald et al reported that abdominoperineal resection was merely required in 23 % of patients with tumours in the lower rectum [ 14 ] . In our institutional series of patients with tumour within 6 centimeter from the anal brink, abdominoperineal resection was performed in merely 29.4 % of patients.
In the original series by Heald et al [ 8 ] , TME was performed in patients with upper rectal malignant neoplastic disease. Routine TME in rectal malignant neoplastic disease at all degrees is now considered unneeded. Lopez-Kostner et al demonstrated that results of intervention of upper rectal malignant neoplastic disease in footings of local return and endurance were similar to those of sigmoid malignant neoplastic disease and that TME was non necessary in upper rectal lesions [ 16 ] .
The present study studied the differences between anterior resection with and without TME utilizing the attack of selective TME harmonizing to the degree of the tumour. It revealed that TME was a more complex operation. The blood loss and continuance of surgery in patients with TME compared favorably with the series of Heald et Al [ 8, 17 ] and Enker et al [ 13 ] every bit good as the study from the multicenter randomized test by the Dutch Colorectal Cancer Group [ 18 ] . However, when compared with anterior resection with PME, operations with TME were associated with a longer operation clip and more blood loss. There was besides a inclination of a higher morbidity rate in patients with TME, although it did non make statistical significance. Furthermore, the average infirmary stay was besides longer in patients with TME.
Anastomotic leak is the of import complication associated with TME. As the hazard of anastomotic escape depends on the degree of the inosculation [ 19-21 ] , the incidence of escape following TME is bound to be high because the colorectal or coloanal inosculation is constantly performed at the degree of the pelvic floor. Karanjia et al reported that the escape rate following TME was 17 % [ 10 ] . In our survey, we found that the escape rate following TME with the inosculation within 5 centimeter from the anal brink was 7.9 % . We besides found that the presence of a recreation pore was an independent factor for a lower anastomotic escape rate. In the present series, with the more broad proximal recreation ( 68.3 % in TME ) , the escape rate following TME was 7.9 % . However, in those patients with anterior resection with PME, the escape rate was merely 2.1 % and recreation pore were merely created in 7.3 % of patients. Surgery with TME was found to an independent factor for anastomotic escape. Therefore, in position of the complexness of the operation, the higher incidence anastomotic escape every bit good as increased likeliness of a recreation pore, the operation should be reserved for those who truly necessitate complete remotion of the mesorectum, viz. , those with the tumours at the mid or distal rectum.
Local return is the most of import step of the oncologic result following rectal malignant neoplastic disease surgery. Conventional rectal surgery, either by abdominoperineal resection or anterior resection, was associated with a high local return rate [ 4-6 ] . The direction of local return is hard and salvage surgery for local return is seldom possible, particularly in instances following TME.
There has been no uniformity in the studies of local return following rectal malignant neoplastic disease surgery. Differences in instance choice and the definition of local return every bit good as the manner of computation are seen in the literature. It is now by and large accepted that the return rate should include both local return entirely and those with distant metastasis. The local return rate should be calculated with the life table method [ 22 ] .
In our survey, the actuarial 5-year local return rate is 10.7 % and this is comparable to most series with TME [ 9, 17, 23-25 ] . This is achieved in a cohort of patients in whom 84 % had advanced tumours ( either transmural invasion and/or lymph node metastasis ) . Radiation therapy was merely given to 5.8 % of patients with healing resection. The phase of the disease and the public presentation of peranal coloanal inosculation were found to be associated with an increased hazard of local return in this group of patients. There was no difference in the local return rate in tumour at upper rectum and rectosigmoid when compared with those in the mid and distal rectum. The local return rates in those patients with and without TME were besides similar. Therefore, anterior resection without TME is appropriate for those with malignant neoplastic disease at the upper rectum and rectosigmoid. In other words, by executing TME in patients with mid and distal rectal malignant neoplastic disease, the local return rate attacks that of the rectal malignant neoplastic diseases situated more proximally.
Those tumours at the really distal rectum that necessitated peranal coloanal inosculation were associated with a high return rate. Peranal coloanal inosculation were largely done in the earlier period of the survey with the tumour within 1 to 2 centimeter from the dentate line. The border of resection was really near in these patients. After our analysis showed the hapless consequences in patients with coloanal inosculation every bit good as those treated with abdominoperineal resection, preoperative chemoradiation was offered to these patients with really distal rectal malignant neoplastic disease in instance of transmural invasion or the presence of lymph node metastasis [ 15 ] . In those patients with inosculation in the pelvic girdle, the local return rate was merely 6.9 % . Although Kapiteijn et Al [ 18 ] showed that preoperative short-course radiation in TME was associated with a lower 2-year local return rate than the group without radiation, the everyday disposal of radiation to all patients with rectal malignant neoplastic disease has non got cosmopolitan credence. Most sawboness would still administrate accessory therapy harmonizing to the consequences of their establishments [ 26 ] . With the low local return rate in patients with inosculation done in the pelvic girdle, we do non experience everyday radiation in this group of patients is justified.
The cancer-specific endurance was 75.5 % , which is comparable with others ‘ consequences [ 9, 23, 24 ] . Survival was related to the histologic features of the tumour such as the phase and the presence of lymphovascular invasion. The degree of the tumour every bit good as whether TME has been performed were non finding factors for endurance. Therefore, tumour at upper rectum and rectosigmoid can be treated without TME to give similar endurance. With the public presentation of TME for mid and distal rectal malignant neoplastic disease, the local return rate of rectal malignant neoplastic disease approaches that of colon malignant neoplastic disease. The endurance would be dependent on the presence of distant metastasis. Zabeer et al [ 27 ] showed that 30 % of the return occurred distantly. Whether endurance following rectal malignant neoplastic disease surgery could be improved with postoperative chemotherapy entirely, as in colonic malignant neoplastic disease, is yet to be seen. In this survey, we could non show survival benefit in patients with accessory chemotherapy. However, a randomized controlled test in this facet is necessary to set up the function of postoperative chemotherapy.
Anterior resection is the safe and preferable option for rectal malignant neoplastic disease with low mortality and acceptable morbidity. Partial mesorectal deletion for malignant neoplastic disease at the upper rectum or rectosigmoid outputs with similar consequences when compared with entire mesorectal deletion for mid and distal rectal malignant neoplastic disease in footings of local return and endurance. However, entire mesorectal deletion is a more complex operation, which is associated with a longer operating clip, more blood loss, longer infirmary stay, a higher escape rate, and a higher pore rate. Thus, selective attack utilizing entire mesorectal deletion for mid and and distal rectal malignant neoplastic disease is more appropriate and sensible attack.