Download Locally recurrent rectal cancer

L APAROSCOPIC APPENDECTOMY: L OCALLY RECURRENT
SHOULD WE CONTINUE?
RECTAL CANCER
Abe Fingerhut
Douglas Wong
Service de Chirugle, Centre Hospitaller Intercommunal, France
Chief, Colorectal Service, Memorial Sloan Kettering Cancer Centre, USA
Although widely practiced, laparoscopic appendectomy (LA) has
Despite advances in the technique of surgical management of
rectal cancer and the use of adjuvant therapy, local recurrence
of rectal cancer remains a significant problem. Prevention of
local recurrence should be a primary goal of the operating surgeon
and the multidisciplinary team. The incidence of local recurrence
following curative resection of rectal cancer ranges from 4% to
33%.1,2,3,4 Some of these patients are potential candidates for
curative re-resection and therapy. This paper will address the
diagnostic work-up and management of this difficult problem.
not met with universal approval. Systematic research of the
literature, analysis and criticism of 21 controlled studies (nearly
2000 patients) on laparoscopic appendectomy and two
randomized studies dealing with diagnostic laparoscopy still
leave doubts as to its usefulness and appropriateness. Because
of questionable quality of most of the randomized controlled
trials (number of patients, exclusions, withdrawals, blinding,
intention-to-treat analysis), publication biases, local practice
variations (hospital stay, rate of enrollment), results regarding
chance of recurrence.6,7 Adherence to the technique of total
mesorectal excision increases the likelihood of achieving negative
margins and resecting tumor deposits in the mesorectum, and
is thus associated with a lower incidence of locally recurrent
rectal cancer.8,9,10,11 Other technical risk factors are implantation
of exfoliated tumor cells; rectal washout techniques decrease the
number of exfoliated cells within the lumen of the rectum, and
may impact local recurrence rates. The technique of resection
has been found to be extremely important in lowering the local
recurrence rate, and eventual outcome following rectal cancer
surgery. A sharp total mesorectal excision technique is advocated,
which is much less likely to compromise the mesorectum than
a blunt dissection technique. In recent years, the surgeon has
been identified as being an independent variable in the potential
for local recurrence.12,13,14
RISK FACTORS FOR LOCAL RECURRENCE
analgesia requirements, return to activity and work, duration of
must be interpreted with caution. The real world of appendicitis
Risk factors for local recurrence can be divided into tumor specific
risk factors, as well as technical risk factors.
probably differs greatly from the atmosphere under which
A. Tumor-specific risk factors
controlled trails comparing LA and OA have been performed.
The more advanced the stage of the primary rectal cancer, the
greater the potential for local recurrence. Stage I rectal cancer
has a very low potential for local recurrence when surgical
resection is done appropriately. The chance of local recurrence
is increased for Stage II and III rectal cancers, even with the use
of adjuvant chemoradiation. High-grade and mucinous rectal
cancers have a higher potential for local recurrence. Other
tumor-specific risk factors include obstructing cancers and locally
perforated cancers. The more distal the location of the tumor
within the rectum, the greater the likelihood of local recurrence.
Lymphovascular invasion and perineural invasion are also
associated with a higher potential for local recurrence. Molecular
markers such as aneuploidy and mutant p-53 gene expression
have been correlated with an increased potential for local
recurrence.5
hospital stay, outcome, follow-up, and antibiotic prophylaxis
Statistical signification of some results found in these trials has
to be weighed against their clinical signification. Consistently
longer operating times (the difference ranging from 8 (ns) to 29
(p<0.0001) min), a minimal reduction in hospital stay (0.1 (ns)
to 2.1 (p<0.007) days), and somewhat more controversial, an
earlier return to normal activity was reported for LA. Data on
analgesic requirements were confusing but wound complications
were more frequent after OA (pooled odds ratio for 10 studies:
2.6 (95% CI 1.3-5.2)). Unsolved problems include national
behavioral problems, age and experience of operating surgeons
(LA or OA), emergency conditions (availability of staff, instruments).
Troubling still is the problem of whether diagnostic laparoscopy
has a real role in appendicitis. Results of cost analysis vary
PROGNOSTIC FACTORS FOR SURGICAL OUTCOME
The duration of time between the resection of the primary rectal
cancer and the eventual diagnosis of a local recurrence is a
prognostic factor for outcome following surgery for local
recurrence. A short interval of less then one year to recurrence
denotes a poor prognostic indicator. This may reflect both the
adequacy of the original surgical resection and/or the biology
of the cancer. The technique of primary resection is clearly a
factor. Patients undergoing a properly conducted total mesorectal
excision have been shown to have a lesser incidence of local
recurrence compared to conventional resection. An isolated true
anastomotic recurrence is a good prognostic factor for eventual
surgical outcome. Many of these anastomotic recurrences are
likely related to implantation of tumor cells in the fresh anastomosis,
and are generally identified at an early stage at endoscopic followup. This makes them more likely to be resectable with negative
margins. Central recurrences, as opposed to peripheral
recurrences, are more likely to be resectable with a negative
margin, and are therefore more amenable to a better surgical
outcome.
according to the standpoint of disease, the patient, the surgeon,
the treatment center, industry and last, society. Three further
B. The technical risk factors
questions may be asked: 1) because of the competition LA vs.
Incomplete or compromised resection for rectal cancer increases
the potential for local recurrence. Clinical and pathological
studies have been correlated, showing that a positive resection
margin carries a high chance of local recurrence, whereas a
curative resection achieving negative margins has a much lower
OA, OA has improved greatly: can it be improved any more?
2) Is there a place or need for further RCT? 3) What is the place
of laparoscopy in the treatment of peritonitis and/or abscess of
appendiceal origin? Answers to these questions are not known
with certainty and should still be discussed.
P.80
P.81
MANAGEMENT OF LOCALLY RECURRENT RECTAL
CANCER
S1 or S2 bony or neural involvement are not candidates for radical
resection. Similarly, patients who are poor surgical risks, with
ASA IV or V classifications, are not candidates for the extent of
surgery necessary to resect a pelvic recurrence.
The management of locally recurrent rectal cancer can be divided
into three phases. Phase 1 involves the diagnosis, evaluation and
preoperative work-up of the patient, with re-staging to define the
extent of disease. Phase 2 involves preoperative chemoradiation
in those patients who are candidates. Phase 3 involves surgical
and ancillary approaches to the local pelvic recurrence.
B. Assessment for preoperative therapy
Patients diagnosed with a pelvic recurrence, who have had no
prior radiation therapy, are candidates for preoperative
chemoradiation in an attempt to downsize the recurrence and
increase the potential for negative margin resectability. If patients
have had limited prior radiation therapy, a modified regime can
be conducted. In patients who have had full dose previous
radiation therapy, then no additional preoperative radiation can
be administered, although aggressive chemotherapy is an option
in select patients. If patients undergo preoperative chemoradiation
prior to definitive surgery, it is a reasonable consideration to
perform re-staging imaging studies, to rule out interval development
of distant metastases, before subjecting the patient to a radical
resection.
A. Diagnostic work-up.
Once the diagnosis of a local recurrence is established, the patient
should undergo a general evaluation and risk assessment. If the
patient is relatively healthy, ASA I-III class without evidence of
distant disease, then the patient may be a candidate for potentially
curative therapy. The patient should undergo re-staging at this
juncture. This is performed to identify any contraindications to
surgical resection. If not already established, histologic verification
of recurrence should be confirmed by either endoscopic biopsy
or a CT-guided biopsy. The work-up should include a complete
clinical examination, and imaging studies to determine resectability
and to rule out distant metastatic disease. Most patients are
initially evaluated by CT imaging, to include the chest, abdomen
and pelvis. CT scanning has been demonstrated to be accurate
in determining resectability of recurrent rectal cancers.15 Once
a pelvic recurrence is established, an MRI of the pelvis with
infusional studies can provide additional valuable information
regarding resectability. The extent of pelvic sidewall involvement,
sacral involvement, and proximity and potential involvement of
the major pelvic and sacral nerve roots, are all best seen with
MRI imaging. Clinical examination can determine if the recurrence
is mobile or only tethered or whether it is a fixed lesion. An
assessment regarding potential resectability can be made by the
clinical examination. Extra-rectal recurrences are often best
imaged by endorectal ultrasonography, particularly when a
relatively small volume recurrence is suspected.16 Extra-rectal
recurrences that can be identified on endorectal ultrasound
imaging are amenable to needle biopsy under ultrasound guidance.
Distant recurrences are best evaluated initially with the CT
imaging, as well as by nuclear medicine scans, with PET scanning
being the current modality of choice.17
C. Surgical Resection
Prior to making the decision regarding resection of the recurrence,
it is paramount that the resectability be carefully evaluated and
determined before offering this to the patient. Having a
multidisciplinary team involved that may include an orthopedic
surgeon, a urologist, and a plastic surgeon is very important to
the overall management of significant pelvic recurrent disease.
The magnitude of the operative procedure and the likelihood of
potential cure need to be very realistically discussed with each
patient. Some surgeons consider that an abdominoperineal
resection should be performed, rather than a sphincter saving
resection, for all resectable pelvic recurrent disease. This is not
universally accepted, and our policy is to offer restorative reresection to patients who have an adequate distal margin of
resection. Nevertheless the potential for a stoma, either permanent
or temporary, should be addressed. The extent of surgery,
prognostic factors and reconstructive issues should be discussed
in detail with patients and their families prior to embarking on
surgical exploration.
Resections for recurrent rectal cancer should be undertaken with
curative intent, although in reality most of these procedures end
up being palliative rather than curative. Careful surgical planning
is mandatory. In pelvic reoperative surgery, the use of preoperative
cystoscopy and placement of bilateral ureteral stents is very
helpful in identifying the ureters and protecting them from
inadvertent iatrogenic injury. A midline abdominal incision is
made. Careful exploration of the abdomen is undertaken, to rule
out undetected extra-pelvic recurrent disease. Depending on
the anticipated extent of the pelvic resection, extra-pelvic disease
is generally considered to be a contraindication to radical resection
Contraindications to resection include extra-pelvis disease, with
the exception of young, fit patients with potentially resectable
distant metastatic disease. Sciatic pain and imaging evidence
of involvement of the sciatic nerve is a contraindication to radical
pelvic surgery for recurrence. Bilateral hydronephrosis is a relative
contraindication, but in some patients amenable to total pelvic
exenteration this does not constitute an absolute contraindication.
In general, patients with circumferential pelvic sidewall
involvement are not candidates for resection, and patients with
P.82
REFERENCES
of the pelvic recurrence. Exceptions to this are in young, fit
patients with potentially resectable distant disease. The next step
in the exploration is to assess the extent of pelvic disease to
determine if resection is technically feasible. In about 15% of
cases exploration will determine that the disease is not resectable.
In such cases the goal of the procedure should be to provide
optimal palliation, particularly where there is imminent risk of
obstruction. Once a decision is made to proceed with resection
of the pelvic recurrence, then mobilization of the small bowel
out of the pelvis to gain adequate access and exposure to the
pelvis is performed. An intraoperative decision is then made as
to the plane of resection, depending on the local extent of the
recurrence. In general, three potential surgical planes of resection
can be considered. For patients having an inadequate primary
resection, the plane between the visceral and the parietal fascia
may still be intact, and in very selected cases this proper plane
of resection can then be dissected. In most instances, however,
the plane of dissection on the pelvic sidewall will be external
to the parietal fascia, along the vessels and nerves of the pelvic
sidewall. This constitutes the second plane of potential resection.
The third plane of potential resection is lateral to the internal
iliac vessels. If the recurrence involves adjacent organs such as
the bladder, seminal vesicles or prostate in a male, or the bladder,
uterus or vagina in the female, or the sacrum, then an extended
resection may be necessary in order to achieve negative margins.
Ideally this possibility should have been already discussed
preoperatively with the patient. It is essential, under these
circumstances, to have a multidisciplinary team in place, in the
event that in continuity resection of major adjacent organs is
necessary, and for reconstructive considerations following
resection. Once the recurrence is resected, frozen sections can
be obtained from the margins of resection. Selective use of
intraoperative radiation therapy, if available, is considered at this
point. This can be administered by either intraoperative external
beam or by brachytherapy. Each modality has its proponents,
and is largely determined by the availability of local expertise.18,19,20
Viable tissue to help close the perineal and pelvic wound is very
helpful in healing. Reconstruction can be aided with the use of
an omental pedicle flap or a myocutaneous flap such as a rectus
abdominis or transposed graciloplasty.21
1.
Heald RJ, Ryall RD. Recurrence and survival after mesorectal excision
for rectal cancer. Lancet 1986; 1:1476.
2.
McDermott FT, Hughes ESR, Pihl E, et al. Local recurrence after
potentially curative resection for rectal cancer in a series of 1008
patients. Br J Surg 1985; 72:34-37.
3.
Rich T, Gunderson LL, Lew R. Patterns of recurrence of rectal cancer
after potentially curative surgery. Cancer 1983; 52:1317-1329.
4.
Philpshen SJ, Heilweil M, Quan SHQ, et al. Patterns of pelvic
recurrence following definitive resections of rectal cancer. Cancer
1984;53:1354-1362.
5.
Liang JT, Cheng YM, Chang KJ, Chien CT, Hsu HC. Reappraisal of
K-ras and p53 gene mutations in the recurrence of Dukes' B2 rectal
cancer after curative resection. Hepatogastroenterology 1999;
46:830-837.
6.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of
rectal adenocarcinoma due to inadequate surgical resection.
Histologic study of later tumor spread and surgical excision. Lancet
1986 ;2:996-999.
7.
Chan KW, Boey J, Wong SK. A method of reporting radial invasion
and surgical clearance of rectal carcinoma. Histopathology 1985;
9:1319-1327.
8.
Heald RJ, Ryall RD. Recurrence and survival after mesorectal excision
for rectal cancer. Lancet 1986; 1:1476.
9.
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal
cancer. Lancet 1993; 341:457-460.
10. Cawthorne SJ, Parums DV, Gibbs NM, et al. Extent of mesorectal
spread and involvement of lateral resection margin as prognostic
factors after surgery for rectal cancer. Lancet 1990; 335:1055-1059.
11. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision
in the operative treatment of carcinoma of the rectum. J Am Coll
Surg 1995; 181:335-346.
12. McArdle CS, Hole D. Impact of variability among surgeons on and
mortality and ultimate survival. BMJ 1991; 302:1501-1505.
13. Philips RKS, Hittinger R, Blesovsy L, Fry JS, Fielding LP. Local
recurrence following curative surgery for large bowel cancer. Br J
Surg 1984; 71:12-16.
14. Hermanek P, Hohenberger W. The importance of volume in colorectal
cancer surgery. Eur Surg Oncol 1996; 22:213-215.
Recurrence after abdominoperineal resection is a difficult
management problem. This is particularly true of male patients,
in which recurrence following abdominoperineal resection almost
always necessitates a pelvic exenteration. In female patients
who have an intact uterus and vagina, the bladder is usually
protected, and resection to incorporate the uterus, ovaries and
posterior vagina is usually adequate, with preservation of the
bladder under these circumstances. Pelvic exenteration when
necessary, while a very radical procedure, does improve chances
of achieving a negative margin, and very satisfactory five-year
15. Farouk R, Nelson H, Radice R, et al. Accuracy of computed
tomography in determining resectability for locally advanced primary
or recurrent colorectal cancers. Am J Surg 1998; 175:283-287.
16. Lohnert MSS, Doniec JM, Henne-Bruns D. Effectiveness of
endoluminal sonography in the identification of occult local rectal
cancer recurrences. Dis Colon Rectum 2000; 4:483-491.
17. Whiteford MH, Whiteford HM, Yee LF, Ogunbiyi OA, Dehdashti
F, Siegel BA, Birnbaum EH, Fleshman JW, Kodner IJ, Read TE,.
Usefulness of FDG-PET scan in the assessment of suspected metastatic
P.83
MANAGEMENT OF LOCALLY RECURRENT RECTAL
CANCER
S1 or S2 bony or neural involvement are not candidates for radical
resection. Similarly, patients who are poor surgical risks, with
ASA IV or V classifications, are not candidates for the extent of
surgery necessary to resect a pelvic recurrence.
The management of locally recurrent rectal cancer can be divided
into three phases. Phase 1 involves the diagnosis, evaluation and
preoperative work-up of the patient, with re-staging to define the
extent of disease. Phase 2 involves preoperative chemoradiation
in those patients who are candidates. Phase 3 involves surgical
and ancillary approaches to the local pelvic recurrence.
B. Assessment for preoperative therapy
Patients diagnosed with a pelvic recurrence, who have had no
prior radiation therapy, are candidates for preoperative
chemoradiation in an attempt to downsize the recurrence and
increase the potential for negative margin resectability. If patients
have had limited prior radiation therapy, a modified regime can
be conducted. In patients who have had full dose previous
radiation therapy, then no additional preoperative radiation can
be administered, although aggressive chemotherapy is an option
in select patients. If patients undergo preoperative chemoradiation
prior to definitive surgery, it is a reasonable consideration to
perform re-staging imaging studies, to rule out interval development
of distant metastases, before subjecting the patient to a radical
resection.
A. Diagnostic work-up.
Once the diagnosis of a local recurrence is established, the patient
should undergo a general evaluation and risk assessment. If the
patient is relatively healthy, ASA I-III class without evidence of
distant disease, then the patient may be a candidate for potentially
curative therapy. The patient should undergo re-staging at this
juncture. This is performed to identify any contraindications to
surgical resection. If not already established, histologic verification
of recurrence should be confirmed by either endoscopic biopsy
or a CT-guided biopsy. The work-up should include a complete
clinical examination, and imaging studies to determine resectability
and to rule out distant metastatic disease. Most patients are
initially evaluated by CT imaging, to include the chest, abdomen
and pelvis. CT scanning has been demonstrated to be accurate
in determining resectability of recurrent rectal cancers.15 Once
a pelvic recurrence is established, an MRI of the pelvis with
infusional studies can provide additional valuable information
regarding resectability. The extent of pelvic sidewall involvement,
sacral involvement, and proximity and potential involvement of
the major pelvic and sacral nerve roots, are all best seen with
MRI imaging. Clinical examination can determine if the recurrence
is mobile or only tethered or whether it is a fixed lesion. An
assessment regarding potential resectability can be made by the
clinical examination. Extra-rectal recurrences are often best
imaged by endorectal ultrasonography, particularly when a
relatively small volume recurrence is suspected.16 Extra-rectal
recurrences that can be identified on endorectal ultrasound
imaging are amenable to needle biopsy under ultrasound guidance.
Distant recurrences are best evaluated initially with the CT
imaging, as well as by nuclear medicine scans, with PET scanning
being the current modality of choice.17
C. Surgical Resection
Prior to making the decision regarding resection of the recurrence,
it is paramount that the resectability be carefully evaluated and
determined before offering this to the patient. Having a
multidisciplinary team involved that may include an orthopedic
surgeon, a urologist, and a plastic surgeon is very important to
the overall management of significant pelvic recurrent disease.
The magnitude of the operative procedure and the likelihood of
potential cure need to be very realistically discussed with each
patient. Some surgeons consider that an abdominoperineal
resection should be performed, rather than a sphincter saving
resection, for all resectable pelvic recurrent disease. This is not
universally accepted, and our policy is to offer restorative reresection to patients who have an adequate distal margin of
resection. Nevertheless the potential for a stoma, either permanent
or temporary, should be addressed. The extent of surgery,
prognostic factors and reconstructive issues should be discussed
in detail with patients and their families prior to embarking on
surgical exploration.
Resections for recurrent rectal cancer should be undertaken with
curative intent, although in reality most of these procedures end
up being palliative rather than curative. Careful surgical planning
is mandatory. In pelvic reoperative surgery, the use of preoperative
cystoscopy and placement of bilateral ureteral stents is very
helpful in identifying the ureters and protecting them from
inadvertent iatrogenic injury. A midline abdominal incision is
made. Careful exploration of the abdomen is undertaken, to rule
out undetected extra-pelvic recurrent disease. Depending on
the anticipated extent of the pelvic resection, extra-pelvic disease
is generally considered to be a contraindication to radical resection
Contraindications to resection include extra-pelvis disease, with
the exception of young, fit patients with potentially resectable
distant metastatic disease. Sciatic pain and imaging evidence
of involvement of the sciatic nerve is a contraindication to radical
pelvic surgery for recurrence. Bilateral hydronephrosis is a relative
contraindication, but in some patients amenable to total pelvic
exenteration this does not constitute an absolute contraindication.
In general, patients with circumferential pelvic sidewall
involvement are not candidates for resection, and patients with
P.82
REFERENCES
of the pelvic recurrence. Exceptions to this are in young, fit
patients with potentially resectable distant disease. The next step
in the exploration is to assess the extent of pelvic disease to
determine if resection is technically feasible. In about 15% of
cases exploration will determine that the disease is not resectable.
In such cases the goal of the procedure should be to provide
optimal palliation, particularly where there is imminent risk of
obstruction. Once a decision is made to proceed with resection
of the pelvic recurrence, then mobilization of the small bowel
out of the pelvis to gain adequate access and exposure to the
pelvis is performed. An intraoperative decision is then made as
to the plane of resection, depending on the local extent of the
recurrence. In general, three potential surgical planes of resection
can be considered. For patients having an inadequate primary
resection, the plane between the visceral and the parietal fascia
may still be intact, and in very selected cases this proper plane
of resection can then be dissected. In most instances, however,
the plane of dissection on the pelvic sidewall will be external
to the parietal fascia, along the vessels and nerves of the pelvic
sidewall. This constitutes the second plane of potential resection.
The third plane of potential resection is lateral to the internal
iliac vessels. If the recurrence involves adjacent organs such as
the bladder, seminal vesicles or prostate in a male, or the bladder,
uterus or vagina in the female, or the sacrum, then an extended
resection may be necessary in order to achieve negative margins.
Ideally this possibility should have been already discussed
preoperatively with the patient. It is essential, under these
circumstances, to have a multidisciplinary team in place, in the
event that in continuity resection of major adjacent organs is
necessary, and for reconstructive considerations following
resection. Once the recurrence is resected, frozen sections can
be obtained from the margins of resection. Selective use of
intraoperative radiation therapy, if available, is considered at this
point. This can be administered by either intraoperative external
beam or by brachytherapy. Each modality has its proponents,
and is largely determined by the availability of local expertise.18,19,20
Viable tissue to help close the perineal and pelvic wound is very
helpful in healing. Reconstruction can be aided with the use of
an omental pedicle flap or a myocutaneous flap such as a rectus
abdominis or transposed graciloplasty.21
1.
Heald RJ, Ryall RD. Recurrence and survival after mesorectal excision
for rectal cancer. Lancet 1986; 1:1476.
2.
McDermott FT, Hughes ESR, Pihl E, et al. Local recurrence after
potentially curative resection for rectal cancer in a series of 1008
patients. Br J Surg 1985; 72:34-37.
3.
Rich T, Gunderson LL, Lew R. Patterns of recurrence of rectal cancer
after potentially curative surgery. Cancer 1983; 52:1317-1329.
4.
Philpshen SJ, Heilweil M, Quan SHQ, et al. Patterns of pelvic
recurrence following definitive resections of rectal cancer. Cancer
1984;53:1354-1362.
5.
Liang JT, Cheng YM, Chang KJ, Chien CT, Hsu HC. Reappraisal of
K-ras and p53 gene mutations in the recurrence of Dukes' B2 rectal
cancer after curative resection. Hepatogastroenterology 1999;
46:830-837.
6.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of
rectal adenocarcinoma due to inadequate surgical resection.
Histologic study of later tumor spread and surgical excision. Lancet
1986 ;2:996-999.
7.
Chan KW, Boey J, Wong SK. A method of reporting radial invasion
and surgical clearance of rectal carcinoma. Histopathology 1985;
9:1319-1327.
8.
Heald RJ, Ryall RD. Recurrence and survival after mesorectal excision
for rectal cancer. Lancet 1986; 1:1476.
9.
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal
cancer. Lancet 1993; 341:457-460.
10. Cawthorne SJ, Parums DV, Gibbs NM, et al. Extent of mesorectal
spread and involvement of lateral resection margin as prognostic
factors after surgery for rectal cancer. Lancet 1990; 335:1055-1059.
11. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision
in the operative treatment of carcinoma of the rectum. J Am Coll
Surg 1995; 181:335-346.
12. McArdle CS, Hole D. Impact of variability among surgeons on and
mortality and ultimate survival. BMJ 1991; 302:1501-1505.
13. Philips RKS, Hittinger R, Blesovsy L, Fry JS, Fielding LP. Local
recurrence following curative surgery for large bowel cancer. Br J
Surg 1984; 71:12-16.
14. Hermanek P, Hohenberger W. The importance of volume in colorectal
cancer surgery. Eur Surg Oncol 1996; 22:213-215.
Recurrence after abdominoperineal resection is a difficult
management problem. This is particularly true of male patients,
in which recurrence following abdominoperineal resection almost
always necessitates a pelvic exenteration. In female patients
who have an intact uterus and vagina, the bladder is usually
protected, and resection to incorporate the uterus, ovaries and
posterior vagina is usually adequate, with preservation of the
bladder under these circumstances. Pelvic exenteration when
necessary, while a very radical procedure, does improve chances
of achieving a negative margin, and very satisfactory five-year
15. Farouk R, Nelson H, Radice R, et al. Accuracy of computed
tomography in determining resectability for locally advanced primary
or recurrent colorectal cancers. Am J Surg 1998; 175:283-287.
16. Lohnert MSS, Doniec JM, Henne-Bruns D. Effectiveness of
endoluminal sonography in the identification of occult local rectal
cancer recurrences. Dis Colon Rectum 2000; 4:483-491.
17. Whiteford MH, Whiteford HM, Yee LF, Ogunbiyi OA, Dehdashti
F, Siegel BA, Birnbaum EH, Fleshman JW, Kodner IJ, Read TE,.
Usefulness of FDG-PET scan in the assessment of suspected metastatic
P.83
O BSTRUCTED COLORECTAL
or recurrent adenocarcinoma of the colon and rectum. Dis Colon
Rectum 2000; 53:759-770.
18. Farouk R, Nelson H, Gunderson L. Aggressive multimodality
treatment for locally advanced irresectable rectal cancer. Br J Surg
1997; 84:741-749.
CARCINOMA
19. Alektiar KM, Zelefsky MJ, Paty PB, Guillem J, Saltz LB, Cohen AM,
Minsky BD. High-dose-rate intraoperative brachytherapy for recurrent
colorectal cancer. Int J Rad Onc Biol Phys 2000; 48:219-226.
William T Chen
20. Hu KS, Harrison LB. Results and complications of surgery combined
with intra-operative radiation therapy for the treatment of locally
advanced or recurrent cancers in the pelvis. Sem Surg Onc 2000;
18:269-278.
Chairman, Colorectal Surgery,
Chang-Hua Christian Medical Center, Chang-Hua, Taiwan
21. Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, Steele G,
Bleday R. Immediate reconstruction of the perineal wound with
gracilis muscle flaps following abdominoperineal resection and
intraoperative radiation therapy for recurrent carcinoma of the
rectum. Ann Surg Oncol 1999; 6:33-37.
22. Estes NC, Thomas JH, Jewell WR, Beggs D, Hardin CA. Pelvic
exenteration: a treatment for failed rectal cancer surgery. Am Surg
1993; 59:420-422.
23. Avradopoulos KA, Vezeridis MP, Wanebo HJ. Pelvic exenteration
for recurrent rectal cancer. Advances in Surgery 1996;29:215-233.
24. Magrini S, Nelson H, Gunderfson LL, et al. Sacropelvic resection
and intraoperative electron irradiation in the management of recurrent
anorectal cancer. Dis Colon Rectum 1996; 39:1-8.
25. Salo JC, Paty PB, Guillem J, Minsky BD, Harrison LB, Cohen AM.
Surgical salvage of recurrent rectal carcinoma after curative resection:
a 10-year experience. Ann Surg Onc 1999; 6:171-177.
The most devastating complication of colorectal carcinoma is
obstruction; it has been associated with poor outcome. An
obstructing carcinoma suggests an advance lesion that frequently
associated with poor nutrition, and/or prospect of metastatic
disease. Obstructed colorectal carcinoma requires emergency
correction and frequently there is no time for pre-operative clinical
workups. Nevertheless, obstructed carcinomas may possibly
require staged surgeries.
of the facility, and mature judgment of a surgeon depending on
the surgeons' familiarity with the surgical practices of colon and
rectal surgery.
The incidence of obstructed colorectal carcinoma is 2-16%1,2
and is commonly the cause of large bowel obstruction for elderly
patients3. One third of the obstructed carcinoma occurs in the
right colon and two thirds in the left colon4. The most common
location of colorectal carcinoma is sigmoid and splenic flexure,
followed by descending colon and ascending colon5.
3. Nivatvongs S, Gordon P. Surgery of the colon, Rectum and Anus:
Quality Medical Publishing, Inc., 1999.
1. Boring CC, Squires TS, Heath CW Jr. Cancer statistics for African
Americans. Cancer 1992; 42:7-17.
2. Serpell JW, Mcdermoot FT, Katrivessis H et al. Obstructing carcinomas
of the colon. Br J Surg 1989; 76:965-969
4. Sjodahl R, Franzen T, Nystrom PO. Primary versus staged resection
of acute obstructing colorectal carcinoma. Br J Surg 1992; 79:685688.
5. Corman ML. Principles of surgical technique in the treatment of
carcinoma of the large bowel. World J Surg 1991; 15:592-596.
Choice of surgical method for obstructed colorectal carcinomas
is controversial. In a patient with obstructed carcinoma is frequently
have a dilated proximal bowel, it is risky to perform a resection
with primary anastomosis in absence of a mechanical bowel
preparation. Many literatures have pointed out the increased
risk of clinically significant anastomotic leakage for one stage
surgery6,7. Because of the risk of perioperative mortality and
morbidity, numerous surgical options have been put forward.
These included, the Paul-Mikulicz procedure8, three stage
procedures, Hartmann's operation8, single stage resection with
primary anastomois with or without on -table lavage, and
endoscopically place expandable metal stent9.
26. Alektiar KM, Zelefsky MJ, Paty PB, Guillem J, Saltz LB, Cohen AM,
Minsky BD. High-dose-rate intraoperative brachytherapy for recurrent
colorectal cancer. Int J Rad Onc Biol Phys 2000; 48:219-226.
6. Schrock TR, Deveney CW, Dunphy JE. Factors contributing to leakage
of intestinal anastomoses. Ann. Surg 1973; 177:513-518
7. Irvin TT, Greaney MG. The treatment of colonic cancer presenting
with intestinal obstruction. Br J Surg 1977; 64(10):741-4.
8. Mcgregor JR, O'Dwyer PJ. The surgical management of obstruction
and perforation of the left colon. Surgery, Gynecology and Obstetrics.
1993; 177:203-208.
9. Saida Y, Sumiyama Y, Nagao J, Takase M. Stent endoscopies for
obstruction colorectal cancers. Dis Colon Rectum 1996; 39:552555.
The surgeon plays an important role in the treatment of the
obstructed carcinoma of the colon and rectum. Early recognition
of the clinical presentation and accurate diagnosis are important.
Intraoperatively, an extra attention to details can avoid disastrous
fecal contamination or tumor spillage. Choice of surgical method
is an important factor to successfully manage of obstructed patient.
The choice among the procedure mentioned above should
depend of the specifics of each patient's condition, the availability
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