Annals of Coloproctology

Review

Colorectal cancer

The role of lateral pelvic lymph node dissection in advanced rectal cancer: a review of current evidence and outcomes: Gyu-Seog Choi, Hye Jin Kim; Ann Coloproctol. 2024;40(4):363-374. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00521.0074

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Metastatic lateral pelvic lymph nodes (LPNs) in rectal cancer significantly impact the prognosis and treatment strategies. Western practices emphasize neoadjuvant chemoradiotherapy (CRT), whereas Eastern approaches often rely on LPN dissection (LPND). This review examines the evolving role of LPND in the context of modern treatments, including total neoadjuvant therapy (TNT), and the impact of CRT on the management of clinically suspicious LPNs. We comprehensively reviewed the key literature comparing the outcomes of LPND versus preoperative CRT for rectal cancer, focusing on recent advancements and ongoing debates. Key studies, including the JCOG0212 trial and recent multicenter trials, were analyzed to assess the efficacy of LPND, particularly in conjunction with preoperative CRT or TNT. Current evidence indicates that LPND can reduce local recurrence rates compared to total mesorectal excision alone in patients not receiving radiation therapy. However, the benefit of LPND in the context of neoadjuvant CRT is influenced by the size and pretreatment characteristics of LPNs. While CRT can effectively control smaller metastatic LPNs, larger or clinically suspicious LPNs may require LPND for optimal outcomes. Advances in surgical techniques, such as robotic-assisted LPND, offer potential benefits but also present challenges and complications. The role of TNT in controlling metastatic LPNs and improving patient outcomes is emerging but remains underexplored. The decision to perform LPND should be individualized based on patient-specific factors, including LPN size, response to neoadjuvant treatment, and surgeon expertise. Future research should focus on optimizing treatment protocols and further evaluating the role of TNT in managing metastatic LPNs.

Citations

Citations to this article as recorded by

From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef

Original Article

Translational/basic research

Exfoliate cancer cell analysis in rectal cancer surgery: comparison of laparoscopic and transanal total mesorectal excision, a pilot study: Kiho You, Jung-Ah Hwang, Dae Kyung Sohn, Dong Woon Lee, Sung Sil Park, Kyung Su Han, Chang Won Hong, Bun Kim, Byung Chang Kim, Sung Chan Park, Jae Hwan Oh; Ann Coloproctol. 2023;39(6):502-512. Published online December 26, 2023; DOI: https://doi.org/10.3393/ac.2023.00479.0068

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Graphical Abstract Abstract PDF Supplementary Material: Purpose
Minimally invasive surgery (MIS) is currently the standard treatment for rectal cancer. However, its limitations include complications and incomplete total mesorectal resection (TME) due to anatomical features and technical difficulties. Transanal TME (TaTME) has been practiced since 2010 to improve this, but there is a risk of local recurrence and intra-abdominal contamination. We aimed to analyze samples obtained through lavage to compare laparoscopic TME (LapTME) and TaTME.
Methods
From June 2020 to January 2021, 20 patients with rectal cancer undergoing MIS were consecutively and prospectively recruited. Samples were collected at the start of surgery, immediately after TME, and after irrigation. The samples were analyzed for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) through a quantitative real-time polymerase chain reaction. The primary outcome was to compare the detected amounts of CEA and CK20 immediately after TME between the surgical methods.
Results
Among the 20 patients, 13 underwent LapTME and 7 underwent TaTME. Tumor location was lower in TaTME (7.3 cm vs. 4.6 cm, P=0.012), and negative mesorectal fascia (MRF) was more in LapTME (76.9% vs. 28.6%, P=0.044). CEA and CK20 levels were high in 3 patients (42.9%) only in TaTME. There was 1 case of T4 with incomplete purse-string suture and 1 case of positive MRF with dissection failure. All patients were followed up for an average of 32.5 months without local recurrence.
Conclusion
CEA and CK20 levels were high only in TaTME and were related to tumor factors or intraoperative events. However, whether the detection amount is clinically related to local recurrence remains unclear.

Review

Pelvic Exenteration: Surgical Approaches: Jin Kim; J Korean Soc Coloproctol. 2012;28(6):286-293. Published online December 31, 2012; DOI: https://doi.org/10.3393/jksc.2012.28.6.286

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Abstract PDF

Although the incidence of local recurrence after curative resection of rectal cancer has decreased due to the understanding of the anatomy of pelvic structures and the adoption of total mesorectal excision, local recurrence in the pelvis still remains a significant and troublesome complication. While surgery for recurrent rectal cancer may offer a chance for a cure, conservative management, including radiation and chemotherapy, remain widely accepted courses of treatment. Recent improvement in imaging modalities, perioperative care, and surgical techniques, including bone resection and wound coverage, have allowed for reductions in operative mortality, though postoperative morbidity still remains high. In this review, the techniques, including surgical approaches, employed for management of locally recurrent rectal cancer are highlighted.

Citations

Citations to this article as recorded by

A radiologist's guide to the galaxy of complications post total pelvic exenteration for rectal cancers
A. Guha, S. Gandhi, S. Mynalli, A. Baheti, P. Haria, A. Choudhari, A. Desouza, A. Saklani, N.S. Shetty, S. Kulkarni
Clinical Radiology.2025; 80: 106719. CrossRef
Quality of Life After Extended Pelvic Surgery with Neurovascular or Bony Resections in Gynecological Oncology: A Systematic Review
Andreas Denys, Sofie Thielemans, Rawand Salihi, Philippe Tummers, Gabrielle H. van Ramshorst
Annals of Surgical Oncology.2024; 31(5): 3280. CrossRef
Outcomes Following Treatment of Pelvic Exenteration for Rectal Cancer in a Tertiary Care Center
Vijayasarathy S, Nizamudheen M. Pareekutty, Satheesan Balasubramanian
Indian Journal of Surgical Oncology.2024; 15(2): 420. CrossRef
Radical resection of locally advanced and recurrent colorectal carcinoma involving major nerve resection: a systematic review of surgical, oncological and functional outcomes
Justin A. Hawke, Samantha Regora, Amrish Rajkomar, Alexander Heriot, Helen Mohan, Satish Warrier
International Journal of Colorectal Disease.2024;[Epub] CrossRef
Rectal cancer pelvic recurrence: imaging patterns and key concepts to guide treatment planning
Akitoshi Inoue, Shannon P. Sheedy, Michael L. Wells, Achille Mileto, Ajit H. Goenka, Eric C. Ehman, Mariana Yalon, Naveen S. Murthy, Kellie L. Mathis, Kevin T. Behm, Sherief F. Shawki, David H. Bruining, Rondell P. Graham, Joel G. Fletcher
Abdominal Radiology.2023; 48(6): 1867. CrossRef
Application of minimally invasive approaches to pelvic exenteration for locally advanced and locally recurrent pelvic malignancy - A narrative review of outcomes in an evolving field
Laura Casey, José Tomás Larach, Peadar S. Waters, Joseph CH. Kong, Jacob J. McCormick, Alexander G. Heriot, Satish K. Warrier
European Journal of Surgical Oncology.2022; 48(11): 2330. CrossRef
Feasibility and short-term outcome of laparoscopic pelvic lymph node dissection in rectal cancer at an University Center
Thinh Nguyen Huu, Huy Tran Duc, Truc Thai Thanh, Vinh Pham Ngoc Truong, Viet Ung Van, An Le Trinh Ngoc, Kien Le Trung, Hung Tran Xuan, Bac Nguyen Hoang
International Journal of Surgery Open.2021; 35: 100366. CrossRef
State-of-the-art surgery for recurrent and locally advanced rectal cancers
Mufaddal Kazi, Vivek Sukumar, Ashwin Desouza, Avanish Saklani
Langenbeck's Archives of Surgery.2021; 406(6): 1763. CrossRef
The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial
Sophie Hogan, Michael Solomon, Anna Rangan, Suzie Ferrie, Sharon Carey
Journal of Parenteral and Enteral Nutrition.2020; 44(5): 806. CrossRef
The Role of Exenterative Surgery in Advanced Urological Neoplasms
Colla Cunneen, Michael Kelly, Gregory Nason, Eanna Ryan, Ben Creavin, Des Winter
Current Urology.2020; 14(2): 57. CrossRef
CT findings after pelvic exenteration: review of normal appearances and most common complications
Martina Sbarra, Maura Miccò, Miriam Corvino, Salvatore Persiani, Benedetta Gui, Valerio Di Paola, Riccardo Manfredi
La radiologia medica.2019; 124(7): 693. CrossRef
Utility of 18F-FDG-PET/CT imaging in patients with recurrent gynecological malignancies prior to pelvic exenteration
Soyoun Rachel Kim, Yoo-Young Lee, Harinder Brar, Arianne Albert, Allan Covens, Ur Metser, Taymaa May
International Journal of Gynecologic Cancer.2019; 29(4): 816. CrossRef
Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries
Prapon Kanjanasilp, Jia Lin Ng, Krittin Kajohnwongsatit, Charnjiroj Thiptanakit, Thitithep Limvorapitak, Chucheep Sahakitrungruang
Diseases of the Colon & Rectum.2019; 62(7): 809. CrossRef
Role of MR Imaging and FDG PET/CT in Selection and Follow-up of Patients Treated with Pelvic Exenteration for Gynecologic Malignancies
Yulia Lakhman, Stephanie Nougaret, Maura Miccò, Chiara Scelzo, Hebert A. Vargas, Ramon E. Sosa, Elizabeth J. Sutton, Dennis S. Chi, Hedvig Hricak, Evis Sala
RadioGraphics.2015; 35(4): 1295. CrossRef
Exenterative Surgery for Advanced Prostate Cancer
Michael E. Kelly, Danielle Courtney, Greg J. Nason, Des C. Winter
Current Surgery Reports.2014;[Epub] CrossRef

Original Article

Abdominoperineal Resection in the Treatment of Locally-advanced Low Rectal Cancer: Is Preoperative Chemoradiation Advantageous?.: Kim, Jeong Yeon , Kim, Jin Soo , Kim, Young Wan , Hur, Hyuk , Min, Byung Soh , Kim, Nam Kyu; J Korean Soc Coloproctol. 2010;26(2):129-136.; DOI: https://doi.org/10.3393/jksc.2010.26.2.129

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Abstract PDF: PURPOSE
An abdominoperineal resection (APR) has a poor prognosis. However, limited studies about the prognostic factors in APR and the role of preoperative chemoradiotherapy (CRT) have been performed even though in rectal cancer, the application of preoperative CRT provides better local control compared to postoperative CRT. The aim of this study was to identify the prognostic factors and the impact of preoperative CRT in patients who undergo an APR.
METHODS
A retrospective analysis was conducted with a total of 133 patients who underwent an APR, cT3, cT4, or cN(+) patients, for rectal cancer between January 1995 and October 2004. Fifty-one patients treated with preoperative CRT (Group 1) were compared with 82 APR patients treated with postoperative CRT (Group 2). Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated.
RESULTS
The median follow-up period was 61.2 mo (range 6 to 194 mo). Circumferential margin (CRM) involvement was significantly associated with local recurrence (LR) and with disease-free survival in APR patients (P<0.001, P=0.011). The 5-yr LR rate was significantly lower in Group 1 than in Group 2 (P=0.013) in the univariate analysis, but no difference was noted in multivariate analysis (P=0.315). In Group 1, CRM involvement, tumor size, and lymph node metastasis were significantly lower than they were in Group 2 (P=0.043, P=0.003, P<0.001).
CONCLUSION
For achieving adequate oncologic outcomes in APR patients, an adequate CRM should be acquired with an optimal operation. In addition, preoperative CRT would be helpful for high-risk APR patients with a threatening CRM margin, providing the benefit of tumor downstaging.

Case Report

Re-anastomosis above a Preceding Anastomosis Made by a Low Anterior Resection.: Shin, Milljae , Yun, Haeran , Lee, Wonseok , Yun, Seonghyeon , Lee, Wooyong , Chun, Ho Kyung; J Korean Soc Coloproctol. 2008;24(4):287-291.; DOI: https://doi.org/10.3393/jksc.2008.24.4.287

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Abstract PDF: Periodic colonoscopic checkup is needed for patients suffering from colorectal cancer, based on the property that a colorectal neoplasm often recurs synchronously or metachronously. Surgical management appropriate to the occasion should be taken in recurrent colorectal cancer. Particularly, recurring colorectal cancer closely above the prior anastomosis for a low anterior resection should be eliminated by using an abdomino-perineal resection, including the preceding anastomotic site or a new anastomotic creation. Under the latter instance, ample possibility exists for postoperative anastomotic stenosis or leakage by reason of insufficient blood supply to the segment between the earlier anastomosis and the later one. The authors report two cases of re-anastomosis for colorectal cancer just above a previous anastomosis taken by a low anterior resection for rectal cancer. In a 52-year-old male with a history of neoadjuvant concomitant chemo-radiotherapy (CCRT) and low anterior resection for rectal cancer located at 6 cm from the anal verge, a new adenocarcinoma was detected 7 cm from the previous anastomotic site and 3 cm from the anal verge. Considering anal sphincter preservation, the re-anastomosis was made at the upper part of the preceding anastomosis. The patient experienced no surgical complications, such as anastomotic stenosis or leakage and functional defecation difficulty. In another patient, a 50-year-old male with a low anterior resection and adjuvant CCRT for rectal cancer 8 cm from anal verge, a new adenocarcinoma was detected in the colon. The new adenocarcinoma was located 10 cm from the anal verge and 8 cm from the previous anastomosis. The same surgical management was applied to this case, with the same postoperative result.

Original Articles

Is a Short Distal Resection Margin of Less than One Centimeter in a Sphincter-saving Resection for Rectal Cancer Oncologically Safe?.: Cho, Min Jeong , Yu, Chang Sik , Park, In Ja , Jeong, Sang Hoon , Chae, Pheung Ha , Hong, Dong Heun , Kim, Dea Dong , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2007;23(6):454-459.; DOI: https://doi.org/10.3393/jksc.2007.23.6.454

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Abstract PDF: PURPOSE
Sphincter preservation is one of the main goals in the treatment of rectal cancer. The aim of this study was to evaluate the oncologic safety of a sphincter-saving resection with a distal resection margin of less than 1 cm.
METHODS
Two hundred forty-eight patients who underwent a sphincter-saving resection between June 1989 and December 2002 and who had a confirmed distal resection margin of less than 1 cm on pathologic examination were included. All patients were evaluated for local and systemic recurrences.
RESULTS
The median follow-up period was 45 (6~144) months. The mean length of distal resection margin was 0.79+/-0.26 cm. Lower rectalcancer was most common (56.5%). Forty patients (16.1%) experienced recurrence. The local recurrence rate was 3.6%, systemic recurrence rate was 11.7%, and the combined local and systemic recurrence rate was 0.4%. In systemic recurrence, the liver was the most common site, followed by the lung. Among stage II & III groups, patients who underwent adjuvant chemoradiotherapy experienced significantly lower local recurrence compared to patients in the chemotherapy-only or the no-adjuvant group (2.6%, 12.9%, 8.7%, P=0.05). The length of distal resection margin, the total mesorectal excision, the location of tumor, sex, histology, and stage were not associated with local recurrence.
CONCLUSIONS
A distal resection margin of less than 1 cm in a sphincter-saving resection showed acceptableoncologic outcomes. Adjuvant chemoradiotherapy were beneficial to reduce local recurrence in the stage II and the stage III groups.

Local Control of Local Excision for T1/T2 Rectal Cancer .: Park, Ki Jae , Choi, Hong Jo , Roh, Young Hoon , Shin, Jong Sok , Lee, Hyung Sik; J Korean Soc Coloproctol. 2007;23(2):87-92.; DOI: https://doi.org/10.3393/jksc.2007.23.2.87

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PURPOSE
The aim of this study was to review the outcome of local control after the local excision for T1/T2 rectal cancers and, thus, to assess its effectiveness as an alternative to a more radical resection.
METHODS
This retrospective study analyzed 23 patients with T1/T2 rectal cancer treated by local excision (LE), and their results were compared with the results for 22 patients with rectal cancer of the same stage treated by a radical resection (RR). All patients with pT2 lesions in the LE group received postoperative adjuvant chemoradiation. The outcomes were defined as 5-year local-recurrence-free survival (LRFS). The median follow-up was 72 (range, 40~92) months.
RESULTS
Recurrence occurred in 4 patients (pT1, 1; pT2, 3) in the LE group and in 3 patients (all pT2) in the the RR group. One patient with vascular invasion (T2N1M0) in the RR group showed multiple liver metastases at 23 months postoperatively. The difference in 5-year LRFS was not statistically significant between the two groups. In the LE group, the 5-year LRFS for pT2 lesions was significantly less favorable than that for pT1 lesions (40% vs. 94%; P= 0.005). The 5-year LRFS for pT2 in the RR group was more favorable than that in the LE group, although the difference was not statistically significant (76.9% vs. 40%, P=0.138). CONSLUSIONS: Local excision provides a favorable local control for pT1 rectal cancers. A more radical resection, however, remains an effective surgical option for pT2 lesions because local excision, even combined with adjuvant chemoradiation, showed substantial local recurrences.

Citations

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Recurrences after Local Excision for Early Rectal Adenocarcinoma
Jung Wook Huh, Yoon Ah Park, Kang Young Lee, Seong Ah Kim, Seung-Kook Sohn
Yonsei Medical Journal.2009; 50(5): 704. CrossRef

Decision of Salvage Treatment after Transanal Endoscopic Microsurgery: Clinical Experience on 36 Cases of Rectal Cancer.: Shin, Suk Hee , Han, Sang Ah , Park, Chi Min , Yun, Seong Hyeon , Lee, Woo Yong , Choi, Dong Wook , Chun, Hokyung; J Korean Soc Coloproctol. 2005;21(6):406-412.

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Abstract PDF: PURPOSE
Local excision, including transanal endoscopic microsurgery (TEM), has become an alternative to the classic radical operation for early rectal cancer. However, radical resection for rectal cancer is necessary for advanced tumor, poor differentiation, a narrow resection margin, and positive lymphovascular invasion. This study presents the factors related to recurrence in patients who required secondary radical surgery after TEM, but did not undergo the operation.
METHODS
From November 1994 to December 2004, 167 patients underwent TEM for rectal cancer. Thirty-six of those patients were included in this study. Inclusion criteria were poor differentiation, a mucinous carcinoma, invasion to a proper muscle layer, lymphovascular invasion, and a positive resection margin.
RESULTS
Twelve of the 36 patients underwent a secondary radical operation, but 24 of them did not due to poor general condition or refusal. One of 12 patients (8.3%) who underwent a secondary radical operation had a systemic recurrence. Five of 24 patients (20.8%) who did not receive surgery had recurrences; 3 of 5 were local recurrence, and the others were distant metastases. Among the 24 patients who did not undergo a secondary radical operation, there were no recurrences in 2 cases of poor differentiation or mucinous carcinoma and in 2 cases of positive resection margin. There were 2 cases of recurrences in the 7 patients (25.0%) who had lymphovascular invasion, 1 case in the 1 patient (100%) who had a T3 lesion, 3 cases in the 17 patients (12.5%) who had T2 lesions.
CONCLUSIONS
In high-risk patients, TEM followed by radical surgery is most beneficial in preventing local recurrence. A radical operation is strongly recommended especially if pathologic results after TEM shows T3 lesions or lymphovascular invasion.

Clinical Analysis of Surgical Treatment for Mid and Lower Rectal Cancers.: Moon, Yang Joo , Kim, Byung Seok , Moon, Duk Jin , Park, Ju Sub; J Korean Soc Coloproctol. 2000;16(6):451-455.

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Abstract PDF: PURPOSE
The aim of this retrospective study was to evaluate the risk of local recurrence such as patients who were treated for Dukes stage B and C low rectal cancer by abdominoperineal resection (APR) or low anterior resection (LAR).
METHODS
From 1985 to 1995, 81 patients with low rectal cancers which were within 3~8 cm from the anal verge were treated by curative resection, 38 by APR and 43 by LAR. The present study examined clinical and tumor characteristics, type of intervention as potential predictors of local recurrence. Retrospective data were analysed by univariate Chi-square tests.
RESULTS
Local recurrence was diagnosed in 17 of 81 patients with a median follow-up period of 24 months. The local recurrence rate was 23.6% (9 of 38) after APR and 18.6% (8 of 43) after LAR. There was no difference in local recurrence between patients who had APR and LAR (P=0.58). Also we could not find any significant differences among age (< or =65 vs >65 years, P=0.53), sex (M vs F, P=0.57), sized of tumors (< or =5 vs >5 cm, P=0.32), distance from anal verge (< or =5 vs >5 cm, P=0.57), Dukes stage (B vs C, P=0.22), histological grade (well and moderate vs poorly, P=0.17), distance from distal resection margin (< or =2 vs >2 cm, P=0.35).
CONCLUSIONS
The tumor factors such as Dukes' stage were more critical for pelvic recurrences than other patient factors.

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