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Transanal extraction found effective in rectal cancer surgery

Key clinical point: Transanal extraction can be recommended in the laparoscopic surgical management of low rectal cancer.

Major finding: During laparoscopic total mesorectal excision, no significant differences were observed between patients who underwent transanal extraction or transabdomonal extraction in the rate of overall mortality (0.8% vs. 0%, respectively; P = 1.000), overall morbidity (34% vs. 43%), or local recurrence (4% vs. 5%; P = .98).

Data source: A single-center study of 220 patients who underwent laparoscopic total mesorectal excision and coloanal anastomosis for rectal cancer at Saint-André Hospital in Bordeaux, France, between 2000 and 2010.

Disclosures: The authors reported having no relevant financial disclosures.


 

FROM ANNALS OF SURGERY

References

Patients who underwent laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer had similar rates of mortality and morbidity, regardless of whether the extraction was performed transanally or transabdominally, a long-term single-center study showed.

“There are few data of full laparoscopic coloanal anastomosis for rectal cancer, including small series and short follow-up,” authors led by Dr. Quentin Denost of the department of surgery at Saint-André Hospital, Bordeau, France, wrote. “Moreover, the risk of anastomotic or perineal recurrence induced by transanal extraction of the rectal specimen is not known.” In addition, they continued, functional outcomes of laparoscopic coloanal anastomosis “have never been reported, and therefore the potential risk of anal incontinence related to transanal specimen extraction has never been discussed.”

In an effort to investigate the long-term outcome of laparoscopic coloanal anastomosis for rectal cancer, the researchers evaluated records of 220 patients who underwent laparoscopic total mesorectal excision and coloanal anastomosis for rectal cancer at Saint-André Hospital between 2000 and 2010 (Ann. Surg. 2014 Sept. 1 [doi:10.1097/SLA.0000000000000855]). Study endpoints of interest were circumferential margin, mesorectal grade, local recurrence, survival, and functional outcome obtained by a questionnaire sent to patients free of disease with at least 1 year of follow-up after stoma closure.

More than half of the patients (63%) were male, their median age was 64, and their median body mass index was 25 kg/m2. The tumors were a median of 4 cm from the anal verge and 1 cm from the anal ring, and 82% of the patients had stage T3 or T4 disease.

The authors reported that the overall mortality and surgical morbidity rates were 0.5% and 17%, respectively, the rate of positive circumferential resection margin was 9%, and the median anal continence score was 6 (range, 0-20). After a median follow-up of 51 months, the local recurrence rate was 4%, while at 5 years, the overall survival and disease-free survival rates were 83% and 70%, respectively.

When the authors evaluated results by extraction site, no significant differences were observed between the transanal extraction and transabdomonal extraction groups in the rate of overall mortality (0.8% vs. 0%, respectively; P = 1.000), overall morbidity (34% vs. 43%), positive circumferential margin (7% vs. 11%; P = .324), mesorectal grade, local recurrence (4% vs. 5%; P = .98), and disease-free survival (72% vs. 68%; P = .63). The median continence score was 6 in both groups (P = .92).

The findings demonstrated that pelvic control and survival “were not compromised by the association between mini invasive surgery and ultralow sphincter preservation,” the authors concluded. “Moreover, we demonstrated the safety and efficacy of transanal extraction of the rectal specimen with similar oncologic and functional outcome than the conventional abdominal extraction. Because of the wound advantages of transanal extraction, in terms of abdominal wall preservation, transanal extraction can be recommended in laparoscopic surgical management of low rectal cancer.”

They acknowledged certain limitations of the study, including the fact that BMI was slightly lower in the transanal group, compared with the transabdomonal group (24.3 vs. 25.8 kg/m2, respectively; P = .01). This suggests “that some obese patients probably received transabdominal instead of transanal extraction,” Dr. Denost and associates wrote. “Therefore, as we recommend preventing excessive stretching of the anal sphincter during rectal extraction, we also recommend to be cautious when performing transanal extraction in obese patients with wide mesorectal specimen, especially to avoid mesorectal injury and tumor spillage.”

The authors reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

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