Adequate Margins of Resection for Rectal and Anal Cancers Can Be Achieved Through a Single-site Laparoscopic Approach

David B Stewart, MD, Evangelos Messaris, MDPhD. Penn State Hershey Medical Center

BACKGROUND: The adequacy of single-site laparoscopic (SSL) resections for malignancies involving the rectum and anus has not been thoroughly analyzed. The present study assesses the margins of resection for consecutive patients undergoing low anterior and abdominoperineal resections for anorectal malignancies.
METHODS: Consecutive rectal and anal cancer patients who underwent SSL by a single surgeon in a single institution from January 2011 through August 2011 were identified. Patient demographics, the use of neoadjuvant therapy and operative details were collected, and complications were sought within 30-days of surgery. Pathology reports were also reviewed to assess both the radial and distal margins of resection as well as the pathologist’s evaluation of the mesorectum.
RESULTS: A total of 9 patients were identified, of whom 7 (77%) were diagnosed with rectal adenocarcinoma, one (11%) was diagnosed with adenocarcinoma of the anal canal, and one (11%) was diagnosed with anal melanoma. Six (66%) patients underwent neoadjuvant chemoradiation, and all but one rectal cancer was located      ≤ 8-cm from the anal verge as measured by rigid proctoscopy. Six (66%) patients underwent a low anterior resection of the rectum with a diverting loop ileostomy, and 3 (33%) patients underwent an abdominoperineal resection. Median patient age was 66 years (range: 44-83) and the median BMI was 30 (range: 24-38), with females comprising 57% of the cohort. Six (66%) patients had Stage III disease, while 3 (33%) patients had Stage IV disease and had undergone neoadjuvant chemotherapy and a previous resection of their hepatic or pulmonary metastases prior to proctectomy. Median operative time was 224 minutes (range: 170-294 minutes) and median estimated blood loss was 100 ml (range: 50-200 ml). There were no conversions to standard laparoscopy or laparotomy, and there were no 30-day complications, including mortality. All margins of resection were clear of tumor by histology. The majority of patients had T2 or T3 cancers (88%); median size of the cancer was 25-mm (range: 0-38 mm). A median of 16 lymph nodes were retrieved (range: 8-41), with 3 (33%) patients having mesorectal nodal involvement with cancer. The closest margin of resection was the radial margin (median: 15mm; range: 12-25mm), while all distal margins of resection were a minimum length of 2-cm (range: 2-8-cm). Intact mesorectal resections were achieved in each surgery.
CONCLUSIONS: Single-site laparoscopic resections for rectal and anal cancers can achieve adequate radial and distal margins of resection, even when operating in the distal pelvis and after preoperative radiotherapy. While SSL may potentially develop into a regularly utilized alternative to standard laparoscopy for rectal and anal cancers in the future, larger prospective studies are needed to validate oncologic outcomes for SSL.

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