Vasileios Kostaras, MD, Andrew R Helber, AB, Gerald J Marks, MD, John H Marks, MD. Marks Colorectal Surgical Associates, Lankenau Institute of Medical Research
Despite the improvements in both survival and quality of life for rectal cancer patients over the last 30 year based on multidisciplinary team (MDT) management, the high rate of incomplete total mesorectal excision (TME), the involvement of circumferential resection margins (CRM), the conversion to open, and the need for APR are still the Achilles heel of the management of distal rectal cancer. Based on the ColorII, ACoSOG Z6071, and AlaCart trials of Laparoscopic vs Open surgery, the rate of complete TME is 82% vs 89% and positive CRM is 12.1% vs 7.7%, respectively. Furthermore, based on the NCDB review of 16,619 patients with stage I-III rectal cancer, the overall positive CRM is high, at 17% (LAR 13%; APR 21%). According to the ROLARR trial, the overall conversion rate to open surgery is 10.1% and, unfortunately, the introduction of robotic surgery has not been the answer to this high conversion rate. We hypothesize that taTME is the answers to the shortcomings of the current management.
A retrospective analysis of a prospectively maintained database of a single colorectal surgeon was performed. During a 53 month period (3/2012-8/2016), 57 patients were selected for treatment of locally advanced cancer (clinical T2-3) of the distal third of the rectum. Of these patients, 50 (87.7%) underwent the TATA procedure and 7 (12.3%) underwent APR. All received neoadjuvant chemoradiation therapy (5-FU and median radiation of 5400 cGy). After radiation, mean tumor size for TATA and APR were 2.79 and 3.29 cm, respectively (p=.20), and mean distance from the anorectal ring were 1.5 and -0.56 cm, respectively (p=0.0015).
There was no conversion to open surgery and no 30-day postoperative mortality in any of the 57 patients. Pathologic grading revealed that 55/57 taTME specimens had "complete" TME, 96% in the TATA group and 100% in APR group (p=0.15). None of the 57 patients had positive CRM. A 15.5 month median follow-up for 51/57 patients revealed that only one patient had a local recurrence: TATA 1/44 (2.3%) and APR 0/7 (0%) (p= 0.31).
The management of distal rectal cancer should be based on evidence based practices, such as a standardized TME technique, appropriate deployment of chemotherapy and radiotherapy, and standardized pathological assessment of resected specimens. The standardization of the taTME technique might overcome the high rate of conversion to open surgery and need for APR.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80335
Program Number: S136
Presentation Session: Colorectal 2
Presentation Type: Podium