ABSTRACT: We read with great interest the article by Asplund et al.  who compared a standard group to an extralevator (EL) group of patients having abdominoperineal excision (APE). In their single institution series the authors found no difference regarding circumferential resection margin positivity, perforation and local recurrence rate. For APE, a wide range of local recurrence rates has been reported in the past (6.4% … 19.7%) [2,3]. This leads to two conclusions: first, there must be a case mix problem that is difficult to address and secondly, there must be variation in surgical technique. Few institutions have reported results for APE that are very similar to the results that we are currently acquainted with for total mesorectal excision (TME)-based anterior resection in rectal carcinoma [2,4,5]. Unfortunately there is not enough detail in the description of the surgical technique to provide an insight into possible reasons for these good results. Obviously 'standard' or 'conventional' APE hardly exist; there are rather differences between individual surgeons or institutions. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.
Colorectal Disease 01/2013; · 2.93 Impact Factor
ABSTRACT: Total fistulectomy with simple closure of the internal opening has been used for the management of complex anal fistulas. This approach involves complete removal of the fistula tract and closure of the internal opening with sutures.
This study aimed to report long-term outcomes in patients with complex cryptoglandular fistulas who undergo this procedure.
This is a retrospective review of a prospectively collected consecutive series.
This study was conducted at a community-based hospital with a specialized colorectal unit.
: Patients included in this study had cryptoglandular fistulas and underwent total fistulectomy with simple closure of the internal opening between 1997 and 2007.
The main outcome measures were success rate and postoperative continence (Cleveland Clinic Florida Fecal Incontinence Scale). Treatment was considered successful if the external opening was closed and no drainage was present at the last follow-up.
Success was achieved in 187 (74%) patients with a median follow-up time of 70 (range, 14-141) months. Patients with posterior transsphincteric or suprasphincteric fistulas had a higher success rate than those with other types of fistulas (82% vs 67%;p = 0.014), and patients for whom the procedure failed were significantly younger than those for whom the procedure was a success (mean, 45 vs 50 years; p = 0.010). Of 160 patients with success who had no previous surgery, 89 (56%) had normal continence postoperatively (CCF-FI score = 0).
The limitations of this study include its retrospective nature, the potential for selection bias, and the lack of preoperative continence scores.
Total fistulectomy with simple closure of the internal opening is effective for the long-term closure of complex cryptoglandular fistulas.However, this procedure may affect continence despite its sphincter-sparing quality. Nonetheless, the high success rate in patients with posterior transsphincteric or suprasphincteric fistulas renders this procedure a reasonable option in this subgroup of patients with complex fistulas.
Diseases of the Colon & Rectum 07/2012; 55(7):750-5. · 3.13 Impact Factor
ABSTRACT: Stapled transanal rectal resection (STARR) has recently been recommended for patients with obstructed defecation caused by rectocele and rectal wall intussusception. Our study investigates the long-term results and predictive factors for outcome.
Between November 2002 and February 2007, 80 patients (69 females) were operated on using the STARR procedure and included in the following study. Symptoms were defined according to the ROME II criteria. Preoperative assessment included clinical examination, colonoscopy, video defecography, and dynamic MRI. Preoperatively and during follow-up visits, we evaluated the Cleveland Constipation Score (CCS) to rate the severity of outlet obstruction and the Wexner Incontinence Score to rate anal incontinence. Patients were asked to judge the outcome of the operation as improved or poor/dissatisfied. We performed a univariate analysis for 11 patient- and disease-related factors to detect an association with outcome.
The median follow-up was 39 months (range 20-78). Major postoperative complications (one staple line insufficiency, one urosepsis, one prolonged urinary dysfunction with indwelling catheter) were found in 3.8%. The result after STARR procedure was a success in the long-term follow-up in 62 patients (77.5%), although the improvement did not persist in 15 patients (18.7%). The mean value of the CCS decreased significantly from 9.3 before surgery to 4.6 after 2 years and increased again slightly to 6.5 after 4-6 years. The Median Wexner Incontinence Score was 3.3 at baseline, but rose significantly to 6.0. However, a third of patients who reported deteriorated continence developed the symptoms 1-4 years after surgery. Of the factors investigated for the prediction of outcome, we could only identify the number of pelvic floor changes in defecography or dynamic MRI as being associated with the success of the operation.
Our study indicates that STARR is a safe procedure. A significant improvement of symptoms is to be expected, but this improvement may deteriorate with time. Patients' satisfaction is also associated with the occurrence of urge to defecate or incontinence. It remains difficult to predict outcome.
Langenbeck s Archives of Surgery 02/2012; 397(5):771-8. · 1.81 Impact Factor
ABSTRACT: Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins.
This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision.
Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy.
A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes.
In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no "self-opening" planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen.
The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed.
The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.
Diseases of the Colon & Rectum 08/2011; 54(8):947-57. · 3.13 Impact Factor
ABSTRACT: After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence.
A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics.
In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups.
This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.
International Journal of Colorectal Disease 05/2011; 26(10):1227-40. · 2.38 Impact Factor
ABSTRACT: Neoadjuvant treatment in the multimodal therapy concept of rectal carcinoma has considerable effects on prognosis appraisal.
This study aimed to evaluate the tumor response specified as an improvement by at least one stage defined in terms of the International Union Against Cancer stages as a prognostic factor.
This investigation was designed as a prospective cohort study.
This study was performed at a community-based hospital with a specialized colorectal unit.
One hundred seventy-four patients with locally advanced rectal carcinoma, treated in the Dresden-Friedrichstadt hospital from 1997 to 2009, who received long-term preoperative chemoradiotherapy and underwent curative resection, were included in this study.
The main outcome measures were cause-specific and disease-free survival with respect to T and N category, International Union Against Cancer stage, venous and lymphatic invasions, grading, CEA level, complete pathologic response, tumor regression grading, International Union Against Cancer stage shift, T, N, and CEA shift, types of neoadjuvant therapy, adjuvant therapy, interval between completion of neoadjuvant chemoradiotherapy and surgery, and number of extracted lymph nodes in resected specimens. Univariate and multivariate analyses were performed.
Median follow-up was 45 months. One hundred twenty-one patients (69.5%) showed a response to the treatment, whereas 53 (30.5%) did not. Five-year cause-specific and disease-free survival for responders (n = 121) vs nonresponders (n = 53) were 92.6% and 73.7% vs 84.9% and 47.9%. In the univariate analysis, ypN category, venous and lymphatic invasion, tumor regression grading, International Union Against Cancer stage shift, and T and N shift were significantly predictive for cause-specific and disease-free survival. Furthermore, ypUICC stage, ypT category, grading, and complete pathologic response had an impact on disease-free survival. In the multivariate analysis, only the International Union Against Cancer stage shift kept its independent explanatory power for cause-specific P = .012, HR 3.10 (95% CI 1.28-7.51) and disease-free survival P < .001, HR 3.85 (95% CI 1.98-7.51).
The determination of International Union Against Cancer stage shift depends on the pretreatment staging modalities.
Our investigation demonstrates that the response of tumor to neoadjuvant therapy is an independent prognostic factor in patients with rectal carcinoma.
Diseases of the Colon & Rectum 04/2011; 54(4):401-11. · 3.13 Impact Factor
ABSTRACT: Extra-levator abdominoperineal excision (ELAPE) has been introduced to avoid oncologic problems encountered with conventional abdominoperineal excision (APE) such as high rates of inadvertent bowel perforation and of positive circumferential resection margin. We compare our short-term results of this new approach with a historic patient cohort.
From 1997 until 2010, we performed 46 consecutive conventional APE and 28 ELAPE after neoadjuvant therapy with a macroscopically complete resection in the true pelvis. Patient data was prospectively collected in our colorectal tumor database. Patient and tumor characteristics were compared as were the rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses.
The rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses were 15.2% vs. 0 (p = 0.04), 4.9% vs. 0 (p = 0.511), and 17.4% vs. 10.7% (p = 0.518), respectively, in the conventional APE vs. ELAPE group.
With a significant reduction of the bowel perforation rate and a reduction of circumferential margin involvement and wound abscess formation, ELAPE improves important surrogate parameters for local recurrence rate and survival.
International Journal of Colorectal Disease 02/2011; 26(7):919-25. · 2.38 Impact Factor
ABSTRACT: In 2007, the German Working Group "Workflow Rectal Cancer II" published 19 quality indicators with 36 quality goals for the treatment of rectal cancer. We investigate whether these parameters are practicable in a specialized coloproctologic unit.
We included 578 consecutive patients with rectal cancer who were treated in our institution from January 2000 to December 2008. Patient data were collected in a prospective database. Follow-up was conducted in a colorectal tumor clinic. Data were analyzed for the defined reference groups, and the results were compared with the quality goals.
Median follow-up was 54.4 (range 1-116) months. We achieved 19 of the 36 defined quality goals. Among these were important parameters such as the rate of postoperative mortality (0.9%), the rate of intraoperative local tumor perforation (2.2% for anterior resection and 8.5% for abdominoperineal excision), the 5-year local recurrence rate (5.9% stages I-III), and the 5-year overall survival rates for stages yII and II (79.9%), and stages yIII and III (60.7%) for patients with microscopically negative resection margins.
Most of the defined quality goals can be achieved in a specialized coloproctologic unit. The debate on quality goals has the potential to enable further improvement in the care of rectal cancer patients.
International Journal of Colorectal Disease 09/2010; 25(9):1093-102. · 2.38 Impact Factor
ABSTRACT: Relative survival estimates are widely used by cancer registries. They provide survival rates adjusted for causes of death other than cancer. They have rarely been used in clinical settings. When compared with cause-specific survival rates or competing risks analysis, their applicability is hardly known. This study compares these three outcome measures on the basis of a well-documented clinical database of patients with colorectal cancer.
We selected a consecutive series of 1,791 histopathologically completely resected colorectal cancer patients without neoadjuvant therapy from a prospective database from 1981 through 2006. Median follow-up was 4.7 (range, 0-23) years with only 3.1% patients lost. Cause-specific and relative survival are reported as failure rates as is the cumulative incidence in the presence of competing risks.
The analysis comprised 1,081 patients with colon cancer and 710 patients with rectal cancer. Stage distribution was as follows: Stage I, 480 patients; Stage II, 785 patients; Stage III, 472 patients; and Stage IV, 54 patients. The "cause-specific" failure rate, the "relative" failure rate, and the cumulative incidence in the presence of competing risks at five years (95% CI) for all patients were 21.1 (range, 19.0-23.4) %, 22.5 (range, 19.6-25.2) %, and 19.0 (range, 17.0-20.9) %, respectively.
Because we could demonstrate almost identical failure rates, we consider relative survival to be a powerful tool in clinical settings in which a comprehensive follow-up is not possible. It is especially useful as a reference parameter for clinical audit.
Diseases of the Colon & Rectum 08/2009; 52(7):1264-71. · 3.13 Impact Factor
ABSTRACT: The time schedule for chemotherapy and primary tumor resection in patients with rectal carcinoma (RC) and unresectable synchronous metastases (USM) is not well defined. We evaluated whether response to chemotherapy is an appropriate criterion for deciding to perform surgery.
We treated 22 patients with RC and USM who received chemotherapy and were regularly evaluated. After documentation of a partial remission (PR) or stable disease (SD), patients were offered resection of the primary tumor. Results were compared with those of a historical control group of 42 patients who underwent immediate surgery.
Seven patients had a PR, four showed SD, and 11 progressed under chemotherapy. Seven patients underwent resection of the primary tumor (no perioperative mortality). The median survival for all 22 patients was 20.2 months. Patients with primary tumor resection survived 27.2 months, whereas patients without resection survived only 12.4 months (p = 0.017). The median survival in the control group was 13.5 months (perioperative mortality, 9.5%).
Chemotherapy and response-dependent resection of the primary tumor results in the same survival time as that attained with immediate surgery. Patients who face a poor prognosis due to progressive disease are thereby spared the risks of major rectal surgery.
Journal of Gastrointestinal Surgery 08/2008; 12(7):1246-50. · 2.83 Impact Factor