Skip to main content

Advertisement

SpringerLink
Log in

Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

This study reports the short- and long-term results for a prospective rectal cancer management program using laparoscopic radical transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) after neoadjuvant therapy.

Methods

A prospective database included 102 rectal cancer patients treated with laparoscopic TATA from 1998 to 2008. Patients with distant metastasis at presentation, patients with a tumor more than 3 cm from the anorectal ring, and patients not undergoing neoadjuvant therapy were excluded, leaving 79 patients (54 men and 25 women) with a mean age of 59.2 years (range, 22–85 years) for this study. 13 patients completed neoadjuvant therapy before the original evaluation, and they are excluded from the report of initial clinical assessment. Before treatment, 50 patients were staged as T3 and 16 patients as T2. The mean level in the rectum superior to the anorectal ring was 1.2 cm (range, −0.5 to 3 cm). In terms of fixity, 31 of the tumors were mobile, 27 were tethered, and 8 showed early fixation. Ulceration was absent in 8 cases, minimal in 12 cases, superficial in 7 cases, moderate in 22 cases, and deep in 17 cases. The mean pretreatment tumor size tumor was 4.8 cm (range, 1.5–12 cm). The median external beam radiation was 5,400 cGy (range, 3,000–8,040 cGy), and 77 patients underwent chemotherapy.

Results

The mean follow-up period was 34.2 months (range, 1.9–113.9 months). There were no perioperative mortalities. The conversion rate was 2.5%, and the mean largest incision length was 4.3 cm (range, 1.2–21 cm). For 84% of the patients, the incision was less than 6.0 cm, and 46% of the patients had no abdominal incision for delivery of the specimen. The mean estimated blood loss was 367 ml (range, 75–2,200 ml). All the patients had a temporary diverting stoma. The major morbidity rate was 11%, and the minor morbidity rate was 19%. The major complications included four full-thickness rectal prolapses with repair, one ischemic neorectum with successful reanastomosis, two bowel obstructions, and two failed anastomoses requiring stoma. The ypT stages included 22 complete responses, 12 cases of ypT1, 22 cases of ypT2, 23 cases of ypT3; 65 cases of ypN0, and 14 cases of ypN + (T3 = 7, T2 = 4, T1 = 3). The local recurrence rate was 2.5% (2/79), and the distant metastases rate was 10.1% (8/79). The KM5YAS rate was 97%. Overall, 90% of the patients lived without a stoma. Neorectal loss was due to positive margins or recurrence and was followed by abdominoperineal resection in three cases and ischemia in two cases. The condition of two patients was not reversed due to comorbidities, and one patient had a stoma secondary to bowel obstruction.

Conclusion

The study results indicate excellent local recurrence (2.7%) and 5-year survival rates without the need for permanent colostomy in patients with cancers in the distal one-third of the rectum. Laparoscopic total mesorectal excision (TME) with the TATA approach is safe and can be performed laparoscopically. Multi-institutional studies are required to establish the reproducibility of this promising approach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Marks GJ, Marks JH, Mohiuddin M, Brady L (1998) Radical sphincter-preservation surgery with coloanal anastomosis following high-dose external irradiation for the very low lying rectal cancer. Recent Results Cancer Res 146:161–174

    CAS  PubMed  Google Scholar 

  2. Marks G, Mohiuddin M, Masoni L, Montori A (1992) High-dose preoperative radiation therapy as the key to extending sphincter preservation surgery for cancer of the distal rectum. Surg Oncol Clin N Am 1:71–85

    Google Scholar 

  3. Swedish Rectal Cancer Trial (1997) Improved survival with preoperative radiotherapy in respectable rectal cancer. New Engl J Med 336:980–987

    Article  Google Scholar 

  4. Crane CH, Skibber JM, Birnbaum EH, Feig BW, Singh AK, Delclos ME, Lin EH, Fleshman JW, Thames HD, Kodner IJ, Lockett MA, Picus J, Phan T, Chandra A, Janjan NA, Read TE, Myerson RJ (2003) The addition of continuous infusion 5-FU to preoperative radiation therapy increases tumor response, leading to increased sphincter preservation in locally advanced rectal cancer. Int J Radiation Biol Phys 57:84–89

    CAS  Google Scholar 

  5. Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740

    Article  CAS  PubMed  Google Scholar 

  6. Stockholm Colorectal Cancer Study Group (1996) Randomized study on preoperative radiotherapy in rectal carcinoma. Ann Surg Onc 3:423–430

    Article  Google Scholar 

  7. Roh MS, Colangelo L, Wieand S, O’Connell M, Petrelli N, Smith R, Mamounas E, Hyams D, Wolmark N (2004) Response to preoperative multimodality therapy predicts survival in patients with carcinoma of the rectum. J Clin Oncol 22:3505

    Google Scholar 

  8. Bosset JF, Collette L, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, Daban A, Bardet E, Beny A, Ollier JC, EORTC Radiotherapy Group Trial 22921 (2006) Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 355:1114–1123

    Article  CAS  PubMed  Google Scholar 

  9. Gérard JP, Conroy T, Bonnetain F, Bouché O, Chapet O, Closon-Dejardin MT, Untereiner M, Leduc B, Francois E, Maurel J, Seitz JF, Buecher B, Mackiewicz R, Ducreux M, Bedenne L (2006) Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3–4 rectal cancers: results of FFCD 9203. J Clin Oncol 24:4620–4625

    Article  PubMed  Google Scholar 

  10. 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 on radiation and chemotherapy on surgical treatment. Dis Colon Rectum 41:1087–1096

    Article  CAS  PubMed  Google Scholar 

  11. 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 downstaging and sphincter preservation with preoperative chomoradiation in locally advanced rectal cancer: the M.D. Anderson cancer center experience. Int J Rad Onc Biol Phys 44:1027–1038

    CAS  Google Scholar 

  12. Hyams DM, Manounas EP, Petrelli N, Rockette H, Jones J, Wieand S, Deutsch M, Wickerham L, Fisher B, Wolmark N (1997) A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum: a progress report of NSABBP R-03. Dis Colon Rectum 40:131–140

    Article  CAS  PubMed  Google Scholar 

  13. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O (2004) Oncologic outcomes after total mesorectal excision for cure of cancer of the lower rectum: anterior vs abdominoperineal resection. Dis Colon Rectum 47:48–58

    Article  PubMed  Google Scholar 

  14. Kapitijin E, Marijnen CAM, Nagtegall ID, Putter H, Steup WH, Wiggers T, Rutten HJT, Pahlman L, Glimelius B, van Krieken JHJM, Leer JWH, van de Welde CJH (2001) Preoperative radiotherapy combined with total mesorectal excision for respectable rectal cancer. N Eng J Med 345:638–646

    Article  Google Scholar 

  15. Marks G, Mohiuddin M, Goldstein SD (1988) Sphincter preservation for cancer of the distal rectum using high dose preoperative radiation. Int, J. Radiation Oncology Biol. Phys 15:1065–1068

    CAS  Google Scholar 

  16. Marks JH, Valsdottir EB, Rather AA et al (2009) Less than 12 lymph nodes can be expected in surgical specimen after high-dose chemoradiation therapy for rectal cancer. Dis Colon Rectum. October 2009. Accepted for publication

  17. Valsdottir EB, Yarandi S, Marks JH, Marks GJ (2008) The quality of life question: preliminary results of a quality-of-life study in rectal cancer patients with radical sphincter preservation surgery following neoadjuvant therapy. Presentation at the 5th international rectal cancer consensus conference, September 2008

  18. Shirouzu K, Isomoto H, Kakegawa T (1995) Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 76:388–392

    Article  CAS  PubMed  Google Scholar 

  19. Kwok SP, Lau WY, Leung KL, Liew CT, Li AK (1996) Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg 83:969–972

    Article  CAS  PubMed  Google Scholar 

  20. Andreola S, Leo E, Belli F, Lavarino C, Bufalino R, Tomasic G, Baldini MT, Valvo F, Navarria P, Lombardi F (1997) Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 40:25–29

    Article  CAS  PubMed  Google Scholar 

  21. Guillem JG, Chessin DB, Shia J, Suriawinata A, Riedel E, Moore HG, Minsky BD, Wong WD (2007) A prospective pathologic analysis using whole-mount sections of rectal cancer following preoperative combined modality therapy: implications for sphincter preservation. Ann Surg 245:88–93

    Article  PubMed  Google Scholar 

  22. Moore HG, Riedel E, Minsky BD, Saltz L, Paty P, Wong D, Cohen AM, Guillem JG (2003) Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol 10:80–85

    Article  PubMed  Google Scholar 

  23. Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumor spread and surgical excision. Lancet 2:996–999

    Article  CAS  PubMed  Google Scholar 

  24. Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P, Dutch Colorectal Cancer Group, The Pathology Review Committee (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23:9257–9264

    Article  PubMed  Google Scholar 

  25. Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F (2005) Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg 241:465–469

    Article  PubMed  Google Scholar 

  26. Chamlou R, Parc Y, Simon T, Bennis M, Dehni N, Parc R, Tiret E (2007) Long-term results of intersphincteric resection for low rectal cancer. Ann Surg 246:916–922

    Article  PubMed  Google Scholar 

  27. Portier G, Ghouti L, Kirzin S, Guimbaud R, Rives M, Lazorthes F (2007) Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma. Br J Surg 94:341–345

    Article  CAS  PubMed  Google Scholar 

  28. Rullier E, Goffre B, Bonnel C, Zerbib F, Caudry M, Saric J (2001) Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum. Ann Surg 234:633–640

    Article  CAS  PubMed  Google Scholar 

  29. Marks G, Mohiuddin M, Masoni L (1993) The reality of radical sphincter-preservation surgery for cancer of the distal 3 cm rectum following high-dose radiation. Int Radiat Oncol Biol Phys 27:779–783

    CAS  Google Scholar 

  30. Rouanet P, Fabre JM, Dubois JB, Dravet F, Saint Aubert B, Pradel J, Ychou M, Solassol C, Pujol H (1995) Conservative surgery for low rectal carcinoma after high-dose radiation: functional and oncologic results. Ann Surg 221:67–73

    Article  CAS  PubMed  Google Scholar 

  31. Mohiuddin M, Regine WF, Marks GJ, Marks JW (1998) High-dose preoperative radiation and the challenge of sphincter preservation surgery for the distal 2 cm of the rectum. Int Radiat Oncol Biol Phys 40:569–574

    CAS  Google Scholar 

  32. Wagman R, Minsky BD, Cohen AM, Guillem JG, Paty PP (1998) Sphincter preservation in rectal cancer with preoperative radiation therapy and coloanal anastomosis: long-term follow-up. Int Radiat Oncol Biol Phys 42:51–57

    CAS  Google Scholar 

  33. Lavery IC, Lopez-Kostner F, Fazio VW, Fernandez-Martin M, Milsom JW, Church J (1997) Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum. Surgery 122:779–785

    Article  CAS  PubMed  Google Scholar 

  34. Gamagami RA, Liagre A, Chiotasso P, Istvan G, Lazorthes F (1999) Coloanal anatomosis for distal third rectal cancer: prospective study of oncologic results. Dis Colon Rectum 42:1272–1275

    Article  CAS  PubMed  Google Scholar 

  35. Leo E, Belli F, Andreola S, Gallino G, Bonfanti G, Ferro F, Zingaro E, Sirizzotti G, Civelli E, Valvo F, Gios M, Brunelli C (2000) Total resection and complete mesorectum excision followed by coloendoanal anastomosis as the optimal treatment for low rectal cancer: the experience of the National Cancer Institute of Milano. Ann Surg Oncol 7:125–132

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosures

John Marks has an equity interest in Covidien, Wolfe, Stryer, Glaxo Smith Kline, Zassi, and Surgiquest and is a consultant to Covidien, Wolfe, Stryker, Glaxo Smith Kline, and Zassi. He is on the Scientific Advisory Board of Surgiquest and serves on the speaker’s bureau of Covidien, Wolfe, and Stryker. He has received educational grant support from Covidien and honoraria from Zassi. B. Mizrahi, I. Nweze, G. Marks, and S. Dalane have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Section of Colorectal Surgery, Lankenau Hospital and Institute for Medical Research, Wynnewood, PA, USA

    J. Marks, B. Mizrahi, S. Dalane, I. Nweze & G. Marks

Authors
  1. J. Marks
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. B. Mizrahi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Dalane
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. I. Nweze
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. G. Marks
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. Marks.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Marks, J., Mizrahi, B., Dalane, S. et al. Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy. Surg Endosc 24, 2700–2707 (2010). https://doi.org/10.1007/s00464-010-1028-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-010-1028-8

Keywords

Search

Navigation