Sphincter Sparing Surgery for the Distal 3 Cm of the True Rectum: Results After Neoadjuvant Therapy and Minimally Invasive Radical Surgery Or Local Excision

George J Nassif, DO, Henry Schoonyoung, MD, Sara Berman, BS, Al Denittis, MD, Erik Zeger, MD, Mo Mohiuddin, MD, Gerald Marks, MD, John H Marks, MD. Lankenau Medical Center

 

Introduction: The characteristics for ideal treatment of rectal cancer include controlling the cancer, minimal morbidity and mortality, minimal trauma to the patient, and avoidance of a colostomy with preservation of adequate function. These goals become more challenging the further distal in the rectum the cancer is located.
 

Hypothesis: Minimally invasive sphincter sparing surgery can accomplish good cancer control, maintaining sphincter function, with minimal morbidity and mortality in rectal cancers of the distal 3 cm after receiving neoadjuvant chemoradiation therapy.

Methods: We retrospectively reviewed data from a prospectively maintained rectal cancer database of a single colorectal surgery practice to identify all patients with cancers of the distal 3 cms undergoing sphincter preservation surgery (SPS) via a laparoscopic total mesorectal excision or local excision by transanal endoscopic microsurgery (TEM). All patients had to have received neoadjuvant therapy. Patient data including demographics, initial tumor characteristics, staging, type dose and response to chemoradiation therapy, operative details, perioperative morbidity and mortality, local recurrence and survival were analyzed.

Results: 161 patients (men=108) underwent SPS by 3 techniques: TATA=106, TEM=49, LAR=6. Average age was 62yo (22-90yo).Mean level in the rectum, from the anorectal ring by procedure was TATA= 1.3cm (-1.0 – 3.0), TEM 1.5cm (-0.5 -3.0). and LAR=2.9cm (2.5-3.0), (p>0.05).  Preoperative T stage of disease by procedure was T3 (N=108): TATA-83, TEM-20, LAR-5; T2 (N=48): TATA-22, TEM-25, LAR-1; T1 (N=3): TATA-1, TEM-2; T4 (N=2): TEM-2. All patients received concomitant 5 FU based chemotherapy and radiation, mean =5300cGy; (3000-7295cGy). Mean EBL was 376cc (10-3600cc). There were no mortalities. Morbidity rate was 0 for LAR; TATA= 13.2%; TEM=32% (Wound disruption Major=10%; Minor=16%). Significant pathologic downstaging occurred with an ypCR of 34% for uT2 and a  ypCR of 19% for uT3. Overall LR=3.7%. By procedure: follow up, local recurrence and KM5yAS were: TATA: 37.9mo/ 3%/ 95%; TEM: 36.3mo/ 6%/ 88%; LAR: 63.1mo/ 0%/ 75% (p>0.05).

Conclusion: Advances in minimally invasive sphincter sparing surgery of rectal cancer promises to further expand curative options after neoadjuvant therapy. This study demonstrates positive oncologic outcomes, low local recurrence rates and high 5 yr survival after minimally invasive sphincter preserving surgery. A colostomy free lifestyle and cancer control make the MIS approach an excellent treatment option for complex distal rectal cancers.

 


Session Number: SS20 – Colorectal
Program Number: S116

« Return to SAGES 2012 abstract archive