Top

Surgical Endoscopy

Published in:

01-06-2011

Laparoscopic total mesorectal excision following long course chemoradiotherapy for locally advanced rectal cancer

Authors: Roger W. Motson, J. S. Khan, T. H. A. Arulampalam, R. C. T. Austin, N. Lacey, B. Sizer

Published in: Surgical Endoscopy | Issue 6/2011

Abstract

Purpose

Laparoscopic total mesorectal excision (TME) of locally advanced rectal cancer after long-course chemoradiotherapy (LCRT) is surgically and oncologically challenging. We have assessed the feasibility, timing, and short-term oncological outcome of laparoscopic TME after LCRT.

Methods

Between 2004 and 2006, 30 patients were selected for LCRT based on clinical examination and MRI. Patients received 3/4 field radiotherapy, 45–50.4 Gy in 25–28 fractions during 5 weeks with either 5-fluorouracil or Uftoral. Clinical assessments were made 4 weeks after completion of radiotherapy and then 2 weekly with sequential 4 weekly MRI, to individualize the timing of surgery at maximal response. Laparoscopic TME was performed using a standard technique.

Results

Thirty patients received LCRT and 26 patients (21 men; median age, 63 years) underwent laparoscopic TME at 11 weeks (median) after LCRT. Median operating time was 270 min. Sixteen patients had LAR and ten had APR. There were three conversions. Three patients developed anastomotic leak (18.7%): one was managed conservatively and one patient died of septicemia. Morbidity was seen in 19% of patients. There were 25 (96%) R0 resections with a complete response in 5 (19%) cases and microscopic tumor in lakes of mucin (Tmic) in another 6 (23%). Two patients (7.6%) developed local recurrence (median follow up, 34 months). The median time interval between radiotherapy and surgery was 11 (range, 7–13) weeks, which was based on serial MRI scans after LCRT.

Conclusions

Laparoscopic TME after LCRT is feasible and safe both oncologically and surgically. Serial MRI helps to determine the optimum timing of surgery.

Daniels I, Fisher S, Heals R, Moran B (2007) Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence. Colorectal Dis 9(4):290–301PubMedCrossRef

Sauer R, Becker H, Hohenberger W et al (2004) German Rectal Cancer Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740PubMedCrossRef

Bosset JF, Calais G, Mineur L et al (2005) Enhanced tumoricidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results–EORTC 22921. J Clin Oncol 23(24):5620–5627PubMedCrossRef

Habr-Gama A, Perez RO, Nadalin W, Nahas SC, Ribeiro U Jr, Silva E, Sousa AH Jr, Campos FG, Kiss DR, Gama-Rodrigues JA (2005) Long-term results of preoperative chemoradiation for distal rectal cancer correlation between final stage and survival. J Gastrointest Surg 9(1):90–99PubMedCrossRef

Habr-Gama A (2006) Assessment and management of the complete clinical response of rectal cancer to chemoradiotherapy. Colorectal Dis 8(Suppl 3):21–24PubMedCrossRef

Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, Allen PK, Lynch PM, Glober G, Wolff R, Rich TA, Skibber J (1999) Tumor down staging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the MD Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 44(5):1027–1038PubMedCrossRef

Minsky BD, Cohen AM, Kemeny N, Enker WE, Kelsen DP, Reichman B, Saltz L, Sigurdson ER, Frankel J (1992) Enhancement of radiation-induced downstaging of rectal cancer by fluorouracil and high-dose leucovorin chemotherapy. J Clin Oncol 10(1):79–84PubMed

Kapiteijn E, Marijnen C, Nagtegaal I, Putter H et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345(9):638–646PubMedCrossRef

Chen ET, Mohiuddin M, Brodovsky H, Fishbein G, Marks G (1994) Downstaging of advanced rectal cancer following combined preoperative chemotherapy and high dose radiation. Int J Radiat Oncol Biol Phys 30:169–175PubMed

10.

Rodríguez-Ramírez SE, Uribe A, Ruiz-García EB, Labastida S, Luna-Pérez P (2006) Risk factors for anastomotic leakage after preoperative chemoradiation therapy and low anterior resection with total mesorectal excision for locally advanced rectal cancer. Rev Invest Clin 58(3):204–210PubMed

11.

Marijnen CA, Kapiteijn E, van de Velde CJ, Martijn H, Steup WH, Wiggers T, Kranenbarg EK, Leer JW, Cooperative Investigators of the Dutch Colorectal Cancer Group (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20(3):817–825PubMedCrossRef

12.

Klessen C, Rogalla P, Taupitz M (2007) Local staging of rectal cancer: the current role of MRI. Eur Radiol 17(2):379–389PubMedCrossRef

13.

Brown G, Richards C, Newcombe R, Dallimore N, Radcliffe A, Carey D, Bourne M, Williams G (1999) Rectal carcinoma: thin-section MR imaging for staging in 28 patients. Radiology 211:215–222PubMed

14.

Beets-Tan R, Beets G, Vliegen R, Kessels A, Boven Van, De Bruine A, von Meyenfeldt M, Baeten C, van Engelshoven J (2001) Accuracy of magnetic resonance imaging in prediction of tumor-free resection margin in rectal cancer surgery. Lancet 357(9255):497–504PubMedCrossRef

15.

MERCURY Study Group (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 333(7572):779CrossRef

16.

Habr-Gama A, Perez R, Proscurshim I, Campos F, Nadalin W, Kiss D, Gama-Rodrigues J et al (2006) Patterns of failure and survival for non-operative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg 10(10):1319–1328PubMedCrossRef

17.

Parvais A, Lawes D, Gilani S, Arulampalam T, Austin R, Motson R (2006) Outcome following laparoscopic rectal resections for cancer: experience with 125 consecutive cases. Surg Endosc 20(Suppl 1):S253

18.

Jayne DG, Guillou P, Thorpe H, Quirke P et al (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25(21):3061–3068PubMedCrossRef

19.

Lacy AM, Garcia-Valdecasas JC, Delgado S et al (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer; a RCT. Lancet 359(9325):2224–2229PubMedCrossRef

20.

Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garrone C (2003) Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 237:335–342PubMed

21.

Arulampalam T, Austin R, Motson R (2005) MRC CLASICC trial. Lancet 366(9487):712PubMedCrossRef

22.

Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477PubMedCrossRef

23.

King PM, Blazeby JM, Ewings P, Franks PJ, Longman R, Kendrick A, Kipling RM, Kennedy RH (2006) Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 93(3):300–308PubMedCrossRef

24.

Motson RW (1994) Direct puncture technique for laparoscopy. Ann R Coll Surg Engl 76(5):346–347PubMed

25.

Nilsson P, Svensson C, Goldman S, Glimelius (2002) Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 89(11):1425–1429PubMedCrossRef

26.

Butler CE, Gündeslioglu AO, Rodriguez-Bigas MA (2008) Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 206(4):694–703PubMedCrossRef

27.

Gerard JP, Romestaing P, Ardiet JM, Mornex F (1998) Endocavitary radiation therapy. Semin Radiat Oncol 8:13–23PubMedCrossRef

28.

Habr-Gama A, de Souza PM, Ribeiro U Jr, Nadalin W, Gansl R, Sousa AH Jr, Campos FG, Gama-Rodrigues J (1998) Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 41(9):1087–1096PubMedCrossRef

29.

Sizer B, Arulampalam T, Austin R, Basu D, Lacey N, Menzies D, Motson R (2007) Individualizing the interval between neoadjuvant chemoradiation with uracil-tegafur (UFT) and total mesorectal excision in magnetic resonance imaging defined poor risk rectal cancer. J Clin Oncol 25(18S):14557

30.

Uzcudun AE, Batlle JF, Velasco JC, Sánchez Santos ME, Carpeño Jde C, Grande AG, Juberías AM, Piñeiro EH, Olivar LM, García AG (2002) Efficacy of preoperative radiation therapy for resectable rectal adenocarcinoma when combined with oral tegafur-uracil modulated with leucovorin: results from a phase II study. Dis Colon Rectum 45(10):1349–1358PubMedCrossRef

31.

Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT (2003) Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg 90:355–364PubMedCrossRef

32.

Mercury Study Group (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. Br Med J 333:779–881CrossRef

33.

Sizer BF, Arulampalam T, Austin R, Lacey N, Menzies D, Motson R (2006) MRI in predicting curative resection of rectal cancer: defining a “window of opportunity” for laparoscopic surgery. BMJ 333(7572):808–809PubMedCrossRef

34.

Johnston DF, Lawrence KM, Sizer BF, Arulampalam TH, Motson RW, Dove E, Lacey N (2009) Locally advanced rectal cancer: histopathological correlation and predictive accuracy of serial MRI after neoadjuvant chemotherapy. Br J Radiol 82(976):332–336PubMedCrossRef

35.

Miyajima N, Fukunaga M, Hasegawa H et al (2009) Results of a multicentre study of 1,057 cases of rectal cancer treated by laparoscopic surgery. Surg Endosc 129:674–680

36.

Leroy J, Jamali F, Forbes L, Smith M, Rubino F, Mutter D, Marescaux J (2004) Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg Endosc 18:281–289PubMedCrossRef

Title: Laparoscopic total mesorectal excision following long course chemoradiotherapy for locally advanced rectal cancer
Authors: Roger W. Motson
J. S. Khan
T. H. A. Arulampalam
R. C. T. Austin
N. Lacey
B. Sizer
Publication date: 01-06-2011
Publisher: Springer-Verlag
Published in: Surgical Endoscopy / Issue 6/2011
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-010-1353-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Laparoscopic total mesorectal excision following long course chemoradiotherapy for locally advanced rectal cancer

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 6/2011

One-stage laparoscopic bisegmentectomy 7–8 and bisegmentectomy 2–3 for bilateral colorectal liver metastases

Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and impact of anti-tumor necrosis factor on postoperative outcomes

Comparison of Billroth I and Billroth II reconstructions after laparoscopy-assisted distal gastrectomy: a retrospective analysis of large-scale multicenter results from Korea

Electrocautery causes more ischemic peritoneal tissue damage than ultrasonic dissection

A new guidewire cannulation technique in ERCP: successful deep biliary access with triple-lumen sphincterotome and guidewire controlled by the endoscopist

A novel ultralow-illumination endoscope system