Advantages of Laparoscopic Abdominoperineal Resection for Anastomotic Recurrence of Rectal Cancer

Local recurrence is the major setback for patients with rectal cancer after surgery. Although the recurrent rate has reduced due to the application of TME and adjuvant therapy, between 2.6 and 32 percents of patients develop local recurrence after curative resection (Heriot et al., 2008). For local recurrence, the subsite is classified into presacral, postero-lateral, lateral, anterior, anastomotic or perineal (Kusters et al., 2009). Patients with anastomotic recurrence have a relatively better prognosis (Matsuda et al., 2010). Nowadays, treatment remains a difficult and challenging problem and no consensus exists as to an optimal treatment approach for local recurrence (Bedrosian et al., 2006). Complete surgical removal offers the only potential for cure and long-term survival (Bedrosian et al., 2006). Minimal invasive surgery which has been extensively accepted by both patients and surgeons represents the development tendency of surgical therapy for colorectal cancer. Till now, there are few reports on the feasibility of laparoscopic resection for patients with anastomotic recurrence of rectal cancer. This retrospective study was designed to evaluate the safety and feasibility of laparoscopic surgery compared with open surgery for anastomotic recurrence of rectal cancer.


Introduction
Local recurrence is the major setback for patients with rectal cancer after surgery.Although the recurrent rate has reduced due to the application of TME and adjuvant therapy, between 2.6 and 32 percents of patients develop local recurrence after curative resection (Heriot et al., 2008).For local recurrence, the subsite is classified into presacral, postero-lateral, lateral, anterior, anastomotic or perineal (Kusters et al., 2009).Patients with anastomotic recurrence have a relatively better prognosis (Matsuda et al., 2010).Nowadays, treatment remains a difficult and challenging problem and no consensus exists as to an optimal treatment approach for local recurrence (Bedrosian et al., 2006).Complete surgical removal offers the only potential for cure and long-term survival (Bedrosian et al., 2006).Minimal invasive surgery which has been extensively accepted by both patients and surgeons represents the development tendency of surgical therapy for colorectal cancer.Till now, there are few reports on the feasibility of laparoscopic resection for patients with anastomotic recurrence of rectal cancer.This retrospective study was designed to evaluate the safety and feasibility of laparoscopic surgery compared with open surgery for anastomotic recurrence of rectal cancer.

Materials and Methods
Data of 42 patients with anastomotic recurrence of rectal cancer underwent curative abdomino-perineal resection in both cancer hospital, Chinese academy of medical sciences (hospital one) and Chengde central hospital (hospital two) between March 2009 and July 2011 was collected retrospectively.Of these 42 cases, 29 cases received treatment in hospital one and 13 cases in hospital two.No neoadjuvant therapy was applied for these patients before receiving previous operation and all patients underwent laparoscopic-assisted resection for previous rectal cancer between March 2007 and June 2010.Pathologic staging was confirmed as T2N0M0 in 3 patients, T3N0M0 in 14 patients, T2N1M0 in 7 patients, T2N2M0 in 6 patients, T3N1M0 in 8 patients and T3N2M0 in 4 patients.No adjuvant therapy was applied for patients with staging of T2N0M0; For T3N0M0, adjuvant therapy was applied for selected patients with high risk factors including poor differentiation, neural invasion and tumor thrombus.6 patients with this staging received adjuvant therapy and 8 patients did not.Adjuvant chemoradiotherapy was applied for all the remaining patients.Postoperative radiotherapy was delivered to a total dose of 50Gy in 25 fractions treating daily for 31 patients.Of the 31 patients, 5-FU+LV was recommended for 17 patients and FOLFOX was recommended for 14 patients.Anastomotic recurrence was confirmed by colonoscopy with biopsy between 13 and 52 months after pervious operation.Physical examination, abdominal ultrasound and barium enema were routinely used for evaluation.Abdominal computed tomography scan (CT), endo-luminal ultrasound and MRI were used to assess the resectability of recurrent rectal cancer.Distance metastasis was excluded from this study.No lateral pelvic wall invasion and sacrum invasion was detected by CT and MRI.cT2N0 was confirmed for rectal recurrent cancer in 16 patients, cT2N+ in 14 patients, cT3N0 in 5 patients and cT3N+ in 7 patients.All patients with cT3N+, 6 patients with cT2N+ and 3 patients with cT3N0 were given preoperative adjuvant therapy (Table 1).Choice of open or laparoscopic resection was strictly based on the patient's individual decision after providing informed consent concerning the methods and risks.The protocol was approved by the ethics committee of our hospital.

Surgical procedure
Of the 42 patients, 22 patients received laparoscopic surgery (LR group) and 20 patients underwent open surgery (OR group).All laparoscopic operations were performed by two experienced surgeons who had completed about 300 laparoscopic rectal operations.Open operations were performed by another two experienced surgeons.For no case with lateral pelvic wall invasion or sacrum invasion, no extended pelvic resection was performed in our study.For laparoscopic surgery, four trocars were used, a 12mm superumbilical port was created to introduce the laparoscope, the other three trocars were created in right lower quadrant (12-mm port), right upper quadrant (5-mm port) and left lower quadrant (5-mm port).Bowel mobilization and dissection of lymph nodes were performed laparoscopically, and the transection of sigmoid colon was performed by an Endoscopic Linear Cutter-Straight (YZB/USA 3859-2010; Ethicon Endosurgery, LLC) under laparoscopy.Perineal operation was implemented after laparoscopic procedure by another two surgeons.Pelvic peritoneal was closed through a small incision which was done in the lower abdomen after perineal operation.An anus praeternaturalis was constructed in left lower quadrant.For open surgery, all abdominal operations were performed through a large incision.

Follow up
All patients were followed up every three months with physical examination and laboratory tests including tumor markers (carcinoem-bryonic antigen, carbohydrate antigen, 19-9).Abdominal computed tomography scan was performed every half a year after operation, colonoscopy and barium enema were performed one year postoperatively.The follow-up time was from 8 to 55 months, and the last follow-up date was October 20th, 2013.Short-term outcomes including operation time, blood loss, status of circumferential resection margin (CRM), number of lymph nodes, time to recovery of intestinal function, complication rate and hospital stay and long-term outcomes including 3-year survival rate and 3-year disease-free survival rate (DFS) were compared between the two groups.

Statistical analysis
Statistical analyses were performed using statistical software package SPSS version 16.0.A p value less than 0.05 was considered to be statistically significant.Categorical variables were analyzed by Chi-square test, and continuous variables were analyzed by the Student's t-test.Survival curves were generated by the Kaplan-Meier method.

Results
No patients in LR group were converted to open surgery, and all patients in the two groups received R0 resection.Age, gender, concomitant diseases, BMI (Body Mass Index), ASA (American Society of Anesthesiologists), distance of recurrent lesion to anal verge, the depth of invasion and size of recurrent lesion were all matched between the two groups (Table 2).All patients in both groups received postoperative chemotherapy.

Short-term outcomes
The mean operative time was 164.6±27.7min in LR group and 203.0±45.3min in OR group (p<0.001), and the mean blood loss in these two groups was 119.7±44.4mland 185.0±94.0ml,respectively (p<0.001).There was  4), there was no statistically significant difference (p=0.915) and the cumulative survival curve was shown in Figure 1.The 3-year DFS was 36.4% and 30.0% in LR group and OR group, respectively (Figure 2), and the difference was not statistically significant (p=0.737).

Discussion
Prognosis of rectal cancer is influenced by local recurrence seriously (Rashid et al., 2009;Zhou et al., 2013).For untreated local recurrence, the median survival ranges from 3.5 to 13 months and the 5-year survival is 0%-5% (Bergamaschi R et al., 1996).However, resection for locally recurrent rectal cancer results in an overall five-year survival of 36.6% and a cancer-specific survival of 41.5%, which is in line with more recent studies (Hahnloser et al., 2003;Moriya et al., 2004;Boyle et al., 2005).An increasing consensus on the fact that surgery should be the first choice if locally recurrent rectal cancer is resectable (Bergamaschi et al., 2001).Anastomotic recurrence has a relatively better prognosis comparing with other types of local recurrence, so aggressive surgical treatment is needed urgently.
So far, Laparoscopic colorectal cancer resection has been accepted extensively by most surgeons and patients.Laparoscopic surgery has been steadily established as a standard operative procedure for patients with colorectal cancer and advantages of this minimal invasive surgery have been confirmed by several studies (Zhou et al., 2004;Lujan et al., 2009).In comparison to open surgery, there is less postoperative pain, quicker recovery, less blood   no significant difference for number of lymph nodes harvested between the two groups (7.3±3.4 vs 7.9±3.4,p=0.466).Time to first flatus in LR group was shorter than that in OR group, and the difference was statistically significant (2.6±0.8 days vs 3.1±0.8days, p=0.013).Time to passing of first defecation in LR group was shorter, but no statistically significant difference (3.3±1.1 days vs 3.6±0.9days, p=0.256) (Table 3).The hospital stay in LR group was 8.6±1.3 days and 9.8±2.2days in OR group (p=0.006).No trocar-related injuries in LR group. 2 patients in LR group and 4 patients in OR group had incision complication; total complication rate in LR group was lower than in OR group in spite of no statistically significant difference (Table 3).

Long-term outcomes
No patients were lost to follow-up.The median loss and shorter hospital stay (King et al., 2006;Ng et al., 2008).There are few reports on the use of laparoscopic technique for the treatment of anastomotic recurrence of rectal cancer.Aimed at evaluating the feasibility and safety of laparoscopic resection for anastomotic recurrence, this study was designed.Oncologic outcome is the focus of every surgeon's attention.Number of lymph nodes harvested (Gao et al., 2013) and status of CRM (Yu et al., 2012) were indexes used for evaluating the oncologic outcome of abdominoperineal resection for low rectal cancer.For rectal cancer, previous studies had shown that number of lymph nodes harvested and resection margins after laparoscopic surgery were equivalent to open surgery (Rezvani et al., 2007;Kang et al., 2010), and the same result could be found in our study.Patients had been implemented radical rectal surgery and postoperative adjuvant therapy in our study, so it is understandable that the number of lymph nodes in both groups was obviously less than what is recommended (Morcos et al., 2010).
Some studies proved that laparoscopic approach can shorten the operation time and reduce the intra-operative blood loss (Yang et al., 2013).For some procedures such as ligation of the inferior mesenteric vessels and dissociation of partial intestinal canal have been completed during the previous operation, operation for recurrent lesion may be simpler.In addition, amplification of laparoscopy and clear view played a very important role in hemostasis, dissociating abdominal cavity adhesion and distal rectum.
Advantages of laparoscopic surgery are reflected by rapider recovery and lower incidence of complication.Avoiding exposure of gastrointestinal tract to external environment may be related to rapider recovery of gastrointestinal function and slighter disturbance of internal environment and avoiding the procedure of pulling the gastrointestinal tract excessively is related to rapider recovery of energy metabolism and visceral protein (Zhang et al., 2008).Previous studies have confirmed that patients underwent laparoscopic surgery had faster recovery of intestinal function compared with who received conventional open surgery (Khoury et al., 2010;Singh et al., 2011).Incision complication reduced as the length of incision shortened, some other complications such as ileus and pulmonary infection had lower incidence resulted from less pain and earlier ambulation.A study designed by Kang et al. (2012) confirmed that laparoscopic colorectal surgery has lower postoperative complications, lower mortality, lower costs and shorter hospital stays.In our study, we found the same results for laparoscopic recurrent lesion resection.
Prognosis of recurrence of rectal cancer can be influenced by several factors.Radical operation or not is the most important one.R0 resection has an obviously better outcome comparing with R1 or R2 resection.Further tumor recurrence after resection of recurrent rectal cancer has been quoted to occur in approximately one-third of patients (Sagar et al., 1996).And several studies (Wiggers et al., 1996;Bozzetti et al., 1997;Bergamaschi et al., 2001) reported that 5-year survivors after resection represent 2%-13% of all patients with locally recurrent rectal cancer occurring either alone or in addition to distant metastases.
Poor prognosis mainly resulted from R1 or R2 resection for some patients.Meanwhile, a study designed by Palmer et al. (2007) showed that locally recurrent patients who underwent curative resection had a 5-year survival rate of 57%.So R0 resection is the crucial reason for reducing re-recurrent rate and improving the survival rate.Patients in both groups received R0 resection in our study.Due to the limitation of follow-up time, we calculated the 3-year survival rate and 3-year DFS.No significant difference could be found for either 3-year survival rate or 3-year DFS between the two groups.
In conclusion, accurate judgment for resectability of anastomotic recurrence is crucial.For resectable recurrence of rectal cancer, laparoscopic abdominoperineal resection had a better short-term outcome and a similar long-term outcome comparing with open resection.Laparoscopic abdomino-perineal resection is feasible and safe for low anastomotic recurrence of rectal cancer.

Table 1 . Comparisons of Two Groups for General Parameters of Patients with Primary Rectal Cancer
Advantages of Laparoscopic Abdominoperineal Resection for Anastomotic Recurrence of Rectal Cancer survival was 36.0 months in LR group and 35.0 months in OR group.The 3-year survival rate was 44.4% and 42.8% in LR group and OR group (Table DOI:http://dx.doi.org/10.7314/APJCP.2014.15.10.4295