Evaluation of the Learning Curve for Conformal Sphincter Preservation Operation in The Treatment of Ultra-Low Rectal Cancer

Abstract Background: To investigate the learning curve of conformal sphincter preservation operation (CSPO) in the treatment of ultra-low rectal cancer and to further expore the influencing factors of operation time.Methods: From August 2011 to April 2020, 108 consecutive patients with ultra-low rectal cancer underwent CSPO by the same surgeon in the department of colorectal surgery of Changhai Hospital. The moving average and cumulative sum control chart (CUSUM) curve were used to analyze the learning curve. The preoperative clinical baseline data, postoperative pathological data, postoperative complications and survival data were compared before and after the completion of learning curve. The influencing factors of CSPO operation time were analyzed by univariate and multivariate analysis.Results: According to the results of moving average and CUSUM method, CSPO learning curve was divided into learning period (1-45 cases) and learning completion period (46-108 cases). There was no significant difference in preoperative clinical baseline data, postoperative pathological data, postoperative complications and survival data between the two stages. Compared with the learning period, the operation time (P < 0.05), blood loss (P < 0.05), postoperative flatus and defecation time (P < 0.05), liquid diet time (P < 0.05) and postoperative hospital stay (P < 0.05) in the learning completion period were significantly reduced, and the difference was statistically significant. Univariate and multivariate analysis showed that distance of tumor from anal verge (≥ 4cm vs. <4cm, P=0.039) and T stage (T3 vs. T1-2, P=0.022) were independent risk factors for prolonging the operation time of CSPO.Conclusions: For surgeons with laparoscopic surgery experience, about 45 cases of CSPO are needed to cross the learning curve. At the initial stage of CSPO, beginners are recommended to select patients with ultra-low rectal cancer whose distance of tumor from anal verge is less than 4cm and tumor stage is less than T3 for practice, which can enable beginners to reduce the operation time, accumulate experience, build self-confidence and shorten the learning curve on the premise of safety.

Download Full-text

Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer

Techniques in Coloproctology ◽

10.1007/s10151-020-02229-2 ◽

2020 ◽

Vol 24 (10) ◽

pp. 1025-1034 ◽

Cited By ~ 1

Author(s):

G. Sun ◽

Z. Lou ◽

H. Zhang ◽

G. Y. Yu ◽

K. Zheng ◽

...

Keyword(s):

Rectal Cancer ◽

Rectal Wall ◽

Anal Verge ◽

Disease Free Survival ◽

Sphincter Preservation ◽

Low Rectal Cancer ◽

Anal Function ◽

Oncological Outcomes ◽

Rectal Cancers ◽

Very Low Rectal Cancer

Abstract Background Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4–5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO. Methods Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed. Results A total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3–4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3–0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12–45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively. Conclusions For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.

Download Full-text

Clinical parameters predictive for sphincter-preserving surgery and prognostic outcome in patients with locally advanced low rectal cancer

10.21203/rs.3.rs-19261/v1 ◽

2020 ◽

Author(s):

Richard Partl ◽

Marton Magyar ◽

Eva Hassler ◽

Tanja Langsenlehner ◽

Karin Sigrid Kapp

Keyword(s):

Rectal Cancer ◽

Karnofsky Performance Status ◽

Anal Verge ◽

Performance Status ◽

Univariate Analysis ◽

Locally Advanced ◽

Sphincter Preservation ◽

Low Rectal Cancer ◽

Clinical Parameters ◽

Histopathological Response

Abstract Background Although controversial, there are data suggesting that clinical parameters can predict the probability of sphincter preserving procedures in rectal cancer. The purpose of this study was to investigate the association between clinical parameters and the sphincter-preserving surgery rate in patients who had undergone neoadjuvant combination therapy for advanced low rectal cancer. Methods In this single center study, the charts of 540 patients with locally advanced rectal cancer who had been treated with induction chemotherapy-and/or neoadjuvant concomitant radiochemotherapy (nRCT) over an 11-year period were reviewed in order to identify patients with rectal cancer ≤6 cm from the anal verge, who had received the prescribed nRCT only. Univariate and multivariate analyses were used to identify pretreatment patient- and tumor associated parameters correlating with sphincter preservation. Survival rates were calculated using Kaplan-Meier analyses. Results 280 of the 540 patients met the selection criteria. Of the 280 patients included in the study, 158 (56.4%) underwent sphincter-preserving surgery. 164 of 280 patients (58.6%) had a downsizing of the primary tumor (ypT < cT) and 39 (23.8%) of these showed a complete histopathological response (ypT0 ypN0). In univariate analysis, age prior to treatment, Karnofsky performance status, clinical T-size, relative lymphocyte value, CRP value, and interval between nRCT and surgery, were significantly associated with sphincter-preserving surgery. In multivariate analysis, age (hazard ratio (HR)=1.05, CI95%: 1.02-1.09, p=0.003), relative lymphocyte value (HR=0.94, CI95%: 0.89-0.99, p=0.029), and interval between nRCT and surgery (HR=2.39, CI95%: 1.17-4.88, p=0.016) remained as independent predictive parameters. A significant longer disease-free (p =0.009) and overall survival (p =0.004) were observed in the sphincter-preserving surgery group. Conclusions The findings of our study in a consistently treated cohort of 280 patients with advanced low rectal cancer suggest that clinical parameters have a role in predicting sphincter-preserving surgery.

Download Full-text

Evaluation of factors determining oncological clearance with sphincter preservation in low rectal cancer

BIRDEM Medical Journal ◽

10.3329/birdem.v10i1.44743 ◽

2019 ◽

Vol 10 (1) ◽

pp. 16-20

Author(s):

Asif Almas Haque ◽

Hasina Alam ◽

Md Rajibul Haque Talukder

Keyword(s):

Rectal Cancer ◽

Surgical Management ◽

Complex Disease ◽

Anal Verge ◽

Muscularis Propria ◽

Sphincter Preservation ◽

Low Rectal Cancer ◽

Clear Understanding ◽

Permanent Colostomy ◽

Number Of Patients

Background: Approximately one third of all colorectal cancers are rectal cancers. It is a peculiar malignancy as resection of this cancer may lead to loss of anal sphincter and the patient is condemned to a permanent colostomy. Aim of the surgery is oncological clearance and sphincter preservation. The optimal surgical management of rectal cancer requires detailed preoperative planning and to determine a logical approach to the management of this complex disease by analyzing the factors that determine its surgical outcome. This study was done to obtain a clear understanding of the factors determining the oncological clearance and sphincter preservation in low rectal carcinoma and thereby guiding surgeons to take appropriate decision in the surgical management. Methods: This prospective observational study, involving 60 consecutive patients with low rectal cancer, was done in Sir Salimullah Medical College and Mitford Hospital, from January 2013 to December 2015. Data were prospectively collected, using detailed proforma and analyzed with a Statistical Package for the Social Sciences (SPSS) version 18.0 and the results were presented in tables. Results: Out of the 60 patients, 40 (67%) had oncological clearance and 26 (43%) had sphincter preservation. A statistically significant number of patients with T1-T2 tumor had oncological clearance [40 (83%) vs 8 (17%), p<0.05]. None of the patients with T3-T4 tumor had curative resection. Whereas, a statistically significant number of patients with tumor distance beyond 5 cm from anal verge, had sphincter preservation [32 (94%) vs 2 (6%), p<0.05]. Most of the patients with tumor within 5 cm [24 (94%) out of 26] had sphincter resection. Conclusion: Tumor factors, favoring sphincter preservation, were ³5 cm distance from anal verge, whereas, circumferential spread limited to muscularis propria (T1-T2), favored oncological clearance. Birdem Med J 2020; 10(1): 16-20

Download Full-text

OUTCOME OF SPHINCTER PRESERVING RECTAL RESECTION FOR LOW RECTAL CANCER

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2017.1.5 ◽

2017 ◽

pp. 36-40

Author(s):

Vinh Quy Truong ◽

Anh Vu Pham ◽

Quang Thuu Le

Keyword(s):

Rectal Cancer ◽

Functional Outcomes ◽

Low Anterior Resection ◽

Rectal Resection ◽

Anal Verge ◽

Low Rectal Cancer ◽

Central Hospital ◽

Mesorectal Excision ◽

Pull Through ◽

Stage T1

Purpose: To evaluate the functional outcome of sphincter-preserving rectal resection for low rectal cancer. Materials and Methods: From April 2009 to January 2016, there are 52 patients who underwent sphincter-preserving rectal resection with total mesorectal excision with low rectal cancer (<6cm from the anal verge) at Hue Central Hospital, Hue, Vietnam. Results: the average age 62.7 ± 12.8, the distance of tumor from anal verge include four group (≤ 3cm 1.9%; 3 to ≤ 4cm 17.3%; 4 to ≤ 5cm 34.6%; > 5 cm). T stage T1/ T2/T3: 1.9%/28.8%/69.2%. The following time is 33.8 ± 18.9 month. Overall recurrence was 13/18(27.1%), local recurrence was 5 (10.4%). Total survival was 40.5 ± 2.9 month. Technique: intersphincteric preservation 14 (26.9%), low anterior resection 17 (32.7%) and pull-through procedure 21 (40.4%). The distance of anatomosis from anal verge: from 1 to ≤ 2 cm:14 (26.9%); from 2 to ≤ 3cm: 21 (40.4%); from 3 to ≤ 4 cm: 17 (32.7%). Bowels movement of 3 month: 4.7 ± 3.2 and 12th month: 2.7 ± 1.6 (p< 0.01). Conclusions: Sphincterpreserving rectal resection using may provide a good continence and oncologic safety. The patients are acceptable with the results of functional outcomes. Key words: Low rectal cancer, sphincter-preserving

Download Full-text

Quality of Life after Sphincter Preservation Surgery or Abdominoperineal Resection for Low Rectal Cancer (ASPIRE): A Long-Term Prospective, Multicentre, Cohort Study

SSRN Electronic Journal ◽

10.2139/ssrn.3697183 ◽

2020 ◽

Author(s):

Sung-Bum Kang ◽

Jung Rae Cho ◽

Seung-Yong Jeong ◽

Jae Hwan Oh ◽

Soyeon Ahn ◽

...

Keyword(s):

Quality Of Life ◽

Rectal Cancer ◽

Cohort Study ◽

Abdominoperineal Resection ◽

Sphincter Preservation ◽

Low Rectal Cancer ◽

Multicentre Cohort Study ◽

Multicentre Cohort

Download Full-text

Can Pre-Treatment Inflammatory Parameters Predict the Probability of Sphincter-Preserving Surgery in Patients with Locally Advanced Low-Lying Rectal Cancer?

Diagnostics ◽

10.3390/diagnostics11060946 ◽

2021 ◽

Vol 11 (6) ◽

pp. 946

Author(s):

Richard Partl ◽

Katarzyna Lukasiak ◽

Bettina Stranz ◽

Eva Hassler ◽

Marton Magyar ◽

...

Keyword(s):

Rectal Cancer ◽

Anal Verge ◽

Locally Advanced ◽

Multivariable Analysis ◽

Sphincter Preservation ◽

Independent Predictive Factor ◽

Lymphocyte Ratio ◽

Inflammatory Parameters ◽

Pre Treatment

There is evidence suggesting that pre-treatment clinical parameters can predict the probability of sphincter-preserving surgery in rectal cancer; however, to date, data on the predictive role of inflammatory parameters on the sphincter-preservation rate are not available. The aim of the present cohort study was to investigate the association between inflammation-based parameters and the sphincter-preserving surgery rate in patients with low-lying locally advanced rectal cancer (LARC). A total of 848 patients with LARC undergoing radiotherapy from 2004 to 2019 were retrospectively reviewed in order to identify patients with rectal cancer localized ≤ 6 cm from the anal verge, treated with neo-adjuvant radiochemotherapy (nRCT) and subsequent surgery. Univariable and multivariable analyses were used to investigate the role of pre-treatment inflammatory parameters, including the C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) for the prediction of sphincter preservation. A total of 363 patients met the inclusion criteria; among them, 210 patients (57.9%) underwent sphincter-preserving surgery, and in 153 patients (42.1%), an abdominoperineal rectum resection was performed. Univariable analysis showed a significant association of the pre-treatment CRP value (OR = 2.548, 95% CI: 1.584–4.097, p < 0.001) with sphincter preservation, whereas the pre-treatment NLR (OR = 1.098, 95% CI: 0.976–1.235, p = 0.120) and PLR (OR = 1.002, 95% CI: 1.000–1.005, p = 0.062) were not significantly associated with the type of surgery. In multivariable analysis, the pre-treatment CRP value (OR = 2.544; 95% CI: 1.314–4.926; p = 0.006) was identified as an independent predictive factor for sphincter-preserving surgery. The findings of the present study suggest that the pre-treatment CRP value represents an independent parameter predicting the probability of sphincter-preserving surgery in patients with low-lying LARC.

Download Full-text