Bradley J. Champagne

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution

BACKGROUND Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. METHODS A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. RESULTS Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. CONCLUSIONS Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.

Re editorial "the controversy regarding hand-assisted colorectal resection".

I greatly enjoyed your well-written and timely editorial, Controversy Regarding Hand-Assisted Colorectal Resection, in the December issue. This topic not only has been controversial but also has been the subject of numerous acrimonious debates at society meetings. I agree with your suggestion that it is necessary to develop the skill set for both techniques, and your argument is well defended. I have three questions. The first two questions pertain to the randomized trial presented at the American Society of Colon and Rectal Surgeons (ASCRS) meeting in 2007 that you cited to support most of your argument for hand-assist technology. First, you commented in your editorial on the improvement in operative times noted for hand-assisted colectomy in this study. Considering that both the principal investigator and other surgeons in the study perform ‘‘hand-assist’’ techniques as their preference in practice, is it any surprise that hand-assist proved to be faster in the study? It is likely that if surgeons who prefer ‘‘straight laparoscopic’’ techniques performed the study, they would have faster operating times in laparoscopic rather than the hand-assisted cases. Second, many of the surgeons who performed this trial recently disclosed that they have stock options in the company that manufactures the principal hand-assist device. Many, if not most, institutional review boards would not permit investigators to accrue patients with this potential conflict of interest. Can you comment on the relevance of this conflict of interest to the interpretation of the study results? Finally, you indicate that hand-assist methods have a role in teaching general surgery residents because of their ‘‘limited time’’ on a colorectal service. As you know, general surgery residents in 2008 have advanced laparoscopic skills that far surpass those of past graduates, perhaps even surpassing the skills possessed by some of their colorectal mentors. Hand-assisted techniques introduce a different new learning curve disparate from laparoscopy. Why, in residents’ ‘‘limited time,’’ do you feel it would it be wise to ‘‘start over’’ by introducing the handassist approach, and what teaching can be performed with a hand in the abdomen (typically that of the attending surgeon) that cannot be done with a 5-mm instrument? Once again, I thank you for your thoughtful and stimulating editorial discussion.