Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
Ann Surg. 2011 Mar;253(3):522-33. doi: 10.1097/SLA.0b013e3182096d4f.
To evaluate the perioperative outcome and long-term survival of patients who underwent surgical resection for recurrent rectal cancer within a multimodal approach in the era of total mesorectal excision (TME).
Introduction of TME has reduced local recurrence and improved oncological outcome of patients with rectal cancer. Local recurrence after TME still occurs in 2% to 8% of patients and presents a challenge to surgical and medical oncologists. However, there has been very limited data on the perioperative and long-term outcome of patients who are operated for local recurrence in the era of TME.
A total of 107 patients who were identified from a prospective rectal cancer database underwent surgical exploration for recurrent rectal cancer after previous TME between October 2001 and April 2009. Risk factors of perioperative morbidity were analyzed using a multivariate logistic regression model. Independent predictors of disease-specific survival were identified by a Cox proportional hazards regression model, as were those of local recurrence and disease recurrence at any site.
Surgical resection was performed in 92 patients and negative resection margins were achieved in 54 (58.7%) of these. Recurrent disease was located intraluminally and extraluminally in 35 (38.0%) patients and 57 (62.0%) patients, respectively. A total of 19 (20.6%) patients had metastatic extrapelvic disease at the time of surgery. Perioperative surgical morbidity and in-hospital mortality accounted for 42.4% and 3.3%, respectively. On multivariate analysis, partial sacrectomy was associated with surgical morbidity (P = 0.004). Three- and 5-year disease-specific survival rates were 61% and 47%. Three-year survival rate of patients with extrapelvic disease who underwent R0 resection was 42%. On multivariate analysis, surgical morbidity (P = 0.001), presence of extrapelvic disease (P = 0.006), and noncurative (R1; R2) resection (P < 0.0001) were identified as independent adverse predictors of disease-specific survival, whereas a transabdominal resection (as opposed to an abdominoperineal resection/pelvic exenteration) was associated with a more favorable prognosis (P = 0.04).
Surgical resection of local recurrence from rectal cancer in the era TME can be carried out with acceptable morbidity and curative resection rates. Curative resection remains the major prognostic factor and may enable long-term survival even in patients with extrapelvic disease.
评估在全直肠系膜切除（TME）时代采用多模式方法对复发性直肠癌患者进行手术切除的围手术期结果和长期生存情况。
TME 的引入降低了直肠癌患者的局部复发率并改善了肿瘤学结果。TME 后仍有 2%至 8%的患者发生局部复发，这对手术和肿瘤内科医生构成了挑战。然而，关于 TME 时代局部复发患者的围手术期和长期结果的数据非常有限。
从 2001 年 10 月至 2009 年 4 月期间的前瞻性直肠癌数据库中确定了 107 名患者，这些患者先前接受了 TME 治疗后接受了复发性直肠癌的手术探查。使用多变量逻辑回归模型分析围手术期发病率的危险因素。通过 Cox 比例风险回归模型确定疾病特异性生存的独立预测因素，以及局部复发和任何部位疾病复发的预测因素。
92 名患者接受了手术切除，其中 54 名（58.7%）获得了阴性切缘。复发疾病在 35 名（38.0%）患者和 57 名（62.0%）患者中分别位于管腔内和管腔外。共有 19 名（20.6%）患者在手术时患有盆腔外转移性疾病。围手术期手术发病率和住院死亡率分别为 42.4%和 3.3%。多变量分析显示，部分骶骨切除术与手术发病率相关（P = 0.004）。3 年和 5 年疾病特异性生存率分别为 61%和 47%。接受 R0 切除的盆腔外疾病患者的 3 年生存率为 42%。多变量分析显示，手术发病率（P = 0.001）、盆腔外疾病的存在（P = 0.006）和非治愈性（R1；R2）切除（P < 0.0001）是疾病特异性生存的独立不良预测因素，而经腹切除（与经腹会阴切除/盆腔切除术相比）与更有利的预后相关（P = 0.04）。
在 TME 时代对直肠癌的局部复发进行手术切除可以获得可接受的发病率和治愈性切除率。治愈性切除仍然是主要的预后因素，即使在患有盆腔外疾病的患者中也能实现长期生存。
