Impact of multimodality treatment on total mesorectal excision (TME) surgery for very low rectal cancers

Abstract

INTRODUCTION: This study reviews the impact of multimodality treatment of either pre-operative, or post-operative chemotherapy and/or radiotherapy on total mesorectal excision (TME) surgery for very low rectal cancers that required either low anterior resection with peranal coloanal anastomosis or abdomino-perineal resection (APR). Results of peri-operative and oncological outcomes of patients will be reviewed from a single institution. MATERIAL AND METHODS: 180 consecutive patients with very low rectal adenocarcinomas within 4 cm from anal verge, who underwent elective TME surgery from 1994 to 2007, were retrospectively analysed. Patients were compared in groups that had surgery only (Grp A), pre-operative chemoradiotherapy then surgery (Grp B), and adjuvant therapy post-operative (Grp C). Dependant variables related to patients, treatments, radiotherapy and tumour were analysed. RESULTS: Over 13 years, there were 180 patients in the prospectively collected database that had very low rectal cancer that required either peranal coloanal anastomosis or abdomino-perineal resection (APR). There were 115 males and 65 female with a mean age of 65.43 years (range 30-89). 134 of them underwent an APR while 46 had a sphincter-preserving ultra-low anterior resection with peranal coloanal anastomosis, combined with defunctioning stomas (40 ileostomies and 6 colostomies). 38 of the surgeries were laparoscopically performed. The cohort had a mean follow-up period of 52.98 months (range: 0.57 to 178.9). 69 patients underwent surgery only, while 58 patients received pre-operative chemoradiotherapy, and 53 patients had post-operative adjuvant therapy in addition to surgery. 9 out of the 58 patients with preoperative chemoradiotherapy could go on to have sphincter-saving rectal resection. The overall peri-operative complication rate was 43.4% in Grp A vs. 29.3% in Grp B vs. 39.6% in Grp C. The local recurrence rate was significantly lower in Grp B (6.9% vs. 21.7% in Grp A vs. 33.9% in GrpC). The overall 30-day mortality was 0.56%(1 patient had small bowel gangrene from Grp A) CONCLUSIONS: Pre-operative chemo radiation in patients with low rectal cancer treated with surgery is not associated with a higher incidence of peri-operative complications. lts benefits may include a higher rate of sphincter-preservation surgery and reduction of local recurrence rate.