Birger H. Endreseth

Transanal Excision vs. Major Surgery for T1 Rectal Cancer

PURPOSEThe purpose of this national study was to examine the long-term results of transanal excision compared with major surgery of T1 rectal cancer.METHODSThis prospective study from the Norwegian Rectal Cancer Project included all 291 patients with a T1M0 tumor within 15 cm from the anal verge treated by anterior resection, abdominoperineal resection, Hartmann’s procedure, or transanal excision in the period from November 1993 to December 1999.RESULTSTwo hundred fifty-six patients were treated by major surgery and 35 patients by transanal excision. None of the patients had neoadjuvant therapy. Macroscopic tumor remnants (R2) occurred in 17 percent (6/35) of the transanal excisions, while major surgery obtained 100 percent R0 resections. Eleven percent of the patients treated with major surgery had glandular involvement. There were no significant differences according to tumor localization, size, or differentiation between Stage I and Stage III tumors. Patients treated with transanal excision were older than patients having major surgery (mean age, 77 vs. 68 years, P < 0.001). After curative resection (R0, R1, Rx) the five-year rate of local recurrence was 12 percent (95 percent confidence interval, 0–24) in the transanal excision group compared with 6 percent (95 percent confidence interval, 2–10) after major surgery (P = 0.010). The overall five-year survival was 70 percent (95 percent confidence interval, 52–88) in the transanal excision group compared with 80 percent (95 percent confidence interval, 74–85) in the major surgery group (P = 0.04) and the five-year disease-free survival was 64 percent (95 percent confidence interval, 46–82) in the transanal excision group compared with 77 percent (95 percent confidence interval, 71–83) in the major surgery group (P = 0.01).CONCLUSIONSThe main problem of transanal excision for early rectal cancer in the present study was the inability to remove all the malignancy. Patients treated with transanal excision had significantly higher rates of local recurrence compared with patients who underwent major surgery. Patients who had transanal excision had inferior survival, but they were older than those who had major surgery.

Circumferential resection margin as a prognostic factor in rectal cancer

This study examined the prognostic impact of the circumferential resection margin (CRM) in patients with rectal cancer treated by total mesorectal excision (TME) with or without radiotherapy.

Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery

Objective  Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM.

Rectal cancer treatment of the elderly

Objective  Life expectancy and incidence of rectal cancer have been increasing. The purpose of this study was to evaluate rectal cancer treatment among very old patients.

Rectal Cancer in the Young Patient

PurposeThe purpose of this national study was to evaluate the results of treatment for young rectal cancer patients.MethodsThis prospective study from the Norwegian Rectal Cancer Project includes all 2,283 patients younger than aged 70 years with adenocarcinoma of the rectum from November 1993 to December 1999. Patients younger than aged 40 years (n = 45), 40 to 44 years (n = 87), 45 to 49 years (n = 153), and 50 to 69 years (n = 1998) were compared for patient and tumor characteristics and five-year overall survival. Patients treated for cure (n = 1,354) were evaluated for local recurrence, distant metastasis, and disease-free survival.ResultsPatients younger than aged 40 years had significantly higher frequencies of poorly differentiated tumors (27 vs. 12–16 percent; P = 0.014), N2-stage (37 vs. 13–18 percent; P = 0.001), and distant metastases (38 vs. 19–24 percent; P = 0.019) compared with older patients. Among those treated for cure, 56 percent of the patients younger than aged 40 years developed distant metastases compared with 20 to 26 percent of the older patients (P = 0.003). Overall five-year survival was 54 percent for patients younger than aged 40years compared with 71 to 88 percent for the older patients (P = 0.029). Age younger than 40 years was a significant independent prognostic factor and increased the risk for metastasis and death.ConclusionsPatients younger than aged 40 years had a more advanced stage at the time of diagnosis and poor prognosis compared with older patients. Young patients treated for cure more often developed distant metastases and had inferior survival.

Improved local control of rectal cancer reduces distant metastases

Aim  The purpose of the present national study was to determine whether improved local control has been accompanied by a change in the incidence of metastases.

Preoperative staging and treatment options in T1 rectal adenocarcinoma

Background. Major rectal resection for T1 rectal cancer offers more than 95% cancer specific five-year survival to patients surviving the first 30 days after surgery. A significant further improvement by development of the surgical technique may not be possible. Improvements in the total survival rate have to come from a more differentiated treatment modality, taking patient and procedure related risk factors into account. Subgroups of patients have operative mortality risks of 10% or more. Operative complications and long-term side effects after rectum resection are frequent and often severe. Results. Local treatment of T1 cancers combined with close follow-up, early salvage surgery or later radical resection of local recurrences or with chemo-radiation may lead to fewer severe complications and comparable, or even better, long-term survival. Accurate preoperative staging and careful selection of patients for local or non-operative treatment are mandatory. As preoperative staging, at present, is not sufficiently accurate, strategies for completion, salvage or rescue surgery is important, and must be accepted by the patient before local treatment for cure is initiated. Recommendations. It is recommended that polyps with low-risk T1 cancers should be treated with endoscopic snare resection in case of Haggitts stage 1 or 2. TEM is recommended if resection margins are uncertain after snare resection for Haggitts stage 3 and 4, and for sessile and flat, low- risk T1 cancers. Average risk patients with high-risk T1 cancers should be offered rectum resection, but old and comorbid patients with high-risk T1 cancers should be treated individually according to objective criteria as age, physical performance as well as patients preference. All patients treated for cure with local resection or non-surgical methods should be followed closely.

What is a safe distal resection margin in rectal cancer patients treated by low anterior resection without preoperative radiotherapy

Aim  The aim of this study was to examine what constitutes an acceptable distal resection margin (DRM) when performing sphincter‐saving surgery for rectal cancer without preoperative radiotherapy.

Surgical load and long-term outcome for patients with Kock continent ileostomy

Objective  The aim of the study was to evaluate the results of Kock continent ileostomy (CI) during the same period when ileal pouch–anal anastomosis was the preferred operation for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP).

Long-term function after ileal pouch-anal anastomosis –Function does not deteriorate with time

Aim  There are conflicting reports regarding long term function after ileal pouch‐anal anastomosis (IPAA). The aim of the present prospective study was to investigate the influence of duration as an independent factor on long‐term function results.