Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
Department of General, Visceral and Vascular Surgery, Catholic Hospital, Mainz, Germany.
World J Surg Oncol. 2019 Oct 8;17(1):168. doi: 10.1186/s12957-019-1705-6.
In rectal cancers, radical surgery should follow local excisions, in cases of unexpected, unfavorable tumor characteristics. The oncological results of this completion surgery are inconsistent. This retrospective cohort study assessed the clinical and long-term oncological outcomes of patients that underwent completion surgery to clarify whether a local excision compromised the results of radical surgery.
Forty-six patients were included, and the reasons for completion surgery, intraoperative complications, residual tumors, local recurrences (LRs), distant metastases, and cancer-specific survival (CSS) were assessed. The results were compared to 583 patients that underwent primary surgery without adjuvant therapy, treated with a curative intention during the same time period.
The median follow-up was 14.6 years. The reasons for undergoing completion surgery were positive resection margins (24%), high-risk cancer (30%), or both (46%). Intraoperative perforations occurred in 10/46 (22%) cases. Residual tumor in the rectal wall or lymph node involvement occurred in 12/46 (26%) cases. The risk of intraoperative perforation and residual tumor increased with the pT category. Intraoperative perforations did not increase postoperative complications, but they increased the risk of LRs in cases of intramural residual tumors (p = 0.003). LRs occurred in 2.6% of pT1/2 and 29% of pT3 tumors. Both the 5- and 10-year CSS rates were 88.8% (95% CI 80.0-98.6). Moreover, the LRs of patients with pT1/2 cancers were lower in patients with completion surgery than in patients with primary surgery.
Rectal wall perforations at the local excision site and residual cancer were the main risks for poor oncological outcomes associated with completion surgery. Local excisions followed by early radical surgery did not appear to compromise outcomes compared to patients with primary surgery for pT1/2 rectal cancer. Improvements in clinical staging should allow more appropriate selection of patients that are eligible for a local excision of rectal cancer.
在直肠肿瘤中，如果局部切除后发现肿瘤特征出乎意料或不利，应进行根治性手术。但这种补救性手术的肿瘤学结果存在差异。本回顾性队列研究评估了接受补救性手术患者的临床和长期肿瘤学结果，以明确局部切除是否会影响根治性手术的结果。
共纳入 46 例患者，评估补救性手术的原因、术中并发症、残留肿瘤、局部复发（LR）、远处转移和癌症特异性生存（CSS）。并与同期接受根治性手术且未接受辅助治疗、以治愈为目的的 583 例患者的结果进行比较。
中位随访时间为 14.6 年。补救性手术的原因包括切缘阳性（24%）、高危癌症（30%）或两者兼有（46%）。术中穿孔发生于 10/46（22%）例患者。直肠壁残留肿瘤或淋巴结受累发生于 12/46（26%）例患者。术中穿孔和残留肿瘤的风险随 pT 分期增加而增加。术中穿孔并未增加术后并发症，但增加了存在壁内残留肿瘤患者发生 LR 的风险（p = 0.003）。LR 发生于 pT1/2 肿瘤患者的 2.6%和 pT3 肿瘤患者的 29%。5 年和 10 年 CSS 率分别为 88.8%（95%CI 80.0-98.6）。此外，pT1/2 肿瘤患者的补救性手术 LR 率低于单纯手术患者。
局部切除部位直肠壁穿孔和残留肿瘤是补救性手术不良肿瘤学结果的主要危险因素。与单纯手术治疗 pT1/2 直肠肿瘤的患者相比，局部切除后早期根治性手术似乎不会影响结局。临床分期的改善应能更准确地选择适合局部切除的直肠肿瘤患者。
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