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OBJECTIVE To evaluate circumferential resection margin (CRM) as a risk factor for distant metastasis (DM) in rectal cancer. SUMMARY BACKGROUND DATA The treatment of rectal cancer has evolved over the last decades. Surgical radicality is considered the most important factor in preventing recurrences including local and distant. CRM ≤1.0 mm is considered to increase recurrence risk. This study explores the risk of DM in relation to exact CRM. METHODS All patients treated with abdominal resection surgery for rectal cancer between 2005 and 2013 in Sweden were eligible for inclusion in this retrospective study. Primary endpoint was DM. RESULTS 12146 cases were identified. 8593 cases were analysed after exclusion. 717 (8.6%) patients had CRM ≤1.0 mm and 7577 (91.4%) patients CRM >1.0 mm. DM recurrence rate at 5 years was 42.1% (95% CI 32.5-50.3), 31.5% (95% CI 27.3-35.5), 25.8% (95% CI 16.2-34.4) and 19.5% (95% CI 18.5-19.5) when CRM was 0.0 mm, 0.1-1.0 mm, 1.1-1.9 mm and CRM ≥2 mm respectively. Multivariable analysis revealed higher DM risk in CRM 0.0-1.0 mm versus >1.0 mm (HR 1.28, 95% c.i. 1.06 to 1.56; P=

To ascertain whether regular β-blocker exposure can improve short- and long-term outcomes after rectal cancer surgery.Surgery for rectal cancer is associated with substantial morbidity and mortality. There is increasing evidence to suggest that there is a survival benefit in patients exposed to β-blockers undergoing non-cardiac surgery. Studies investigating the effects on outcomes in patients subjected to surgery for rectal cancer are lacking.All adult patients undergoing elective abdominal resection for rectal cancer over a 10-year period were recruited from the prospectively collected Swedish Colorectal Cancer Registry. Patients were subdivided according to preoperative β-blocker exposure status. Outcomes of interest were 30-day complications, 30-day cause-specific mortality, and 1-year all-cause mortality. The association between β-blocker use and outcomes were analyzed using Poisson regression model with robust standard errors for 30-day complications and cause-specific mortality. One-year survival was assessed using Cox proportional hazards regression model.A total of 11,966 patients were included in the current study, of whom 3513 (29.36%) were exposed to regular preoperative β-blockers. A significant decrease in 30-day mortality was detected (incidence rate ratio = 0.06, 95% confidence interval: 0.03-0.13, P0.001). Deaths of cardiovascular nature, respiratory origin, sepsis, and multiorgan failure were significantly lower in β-blocker users, as were the incidences in postoperative infection and anastomotic failure. The β-blocker positive group had significantly better survival up to 1 year postoperatively with a risk reduction of 57% (hazard ratio = 0.43, 95% confidence interval: 0.37-0.52, P0.001).Preoperative β-blocker use is strongly associated with improved survival and morbidity after abdominal resection for rectal cancer.

OBJECTIVE: The aim of this study was to evaluate whether the abdominoperineal excision (APE) is associated with an increased risk of circumferential resection margin (CRM) involvement after rectal cancer surgery in comparison with low anterior resection (LAR). BACKGROUND: The oncologic inferiority of the APE technique in comparison with LAR has been widely reported in literature. However, because of large evolvement in rectal cancer care, outcomes after APE may have improved since then. METHODS: The population-based dataset of the Dutch Surgical Colorectal Audit was used selecting 5017 patients with primary rectal cancer undergoing surgery in 2010 to 2011. Propensity scores were calculated for the likelihood of performing an APE given relevant patient and tumor characteristics, and used in the multivariate analysis of CRM involvement. RESULTS: The APE was associated with a slight, nonsignificant, increased risk of CRM involvement [odds ratio (OR) = 1.33; confidence interval (CI) = 0.93-1.90]. Absolute percentages of CRM involvement were 8% and 12% after LAR and APE, respectively.In the subgroup analysis, advanced rectal tumors (cT3-4) were associated to a higher risk of CRM involvement after APE (OR = 1.61; CI = 1.05-1.90), whereas smaller tumors (cT1-2) were not (OR = 0.62; CI = 0.27-1.40). CONCLUSIONS: The results suggest that on a national level the APE procedure itself is not a strong predictor anymore for CRM involvement after rectal cancer surgery. However, in advanced tumors, results after APE are inferior to LAR.

To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States.Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown.Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis.A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985).Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

This systematic review was designed to determine postoperative complication rates of radical surgery for rectal cancer (abdominal perineal resection and anterior resection).Lack of accepted complication rates for rectal cancer surgery may hinder quality improvement efforts and may impede the conception of future studies because of uncertainty regarding the expected event rates.All prospective studies of rectal cancer receiving radical surgery published between 1990 and August 2008 were obtained by searching Ovid MEDLINE, EMBASE, as well as ASCO GI, CAGS, and ASCRS meeting abstracts between 2004 and 2008. There was no language restriction. The outcomes extracted were anastomotic leak, pelvic sepsis, postoperative death, wound infection, and fecal incontinence. Summary complication rates were obtained using a random effects model; the Z-test was used to test for study heterogeneity.Fifty-three prospective cohort studies and 45 randomized controlled studies with 36,315 patients (24,845 patients had an anastomosis) were eligible for inclusion. Most of the studies found were based in continental Europe (58%), followed by Asia (25%), United Kingdom (10%), North America (5%), and Australia/New Zealand. The anastomotic leak rate, reported in 84 studies, was 11% (95% CI: 10, 12); the pelvic sepsis rate, in 29 studies, was 12% (9, 16); the postoperative death rate, in 75 studies, was 2% (2, 3); and the wound infection rate, in 50 studies, was 7% (5, 8). Fecal incontinence rates were reported in too few studies and so heterogeneously that numerical summarization was inappropriate. Year of publication, use of preoperative radiation, use of laparoscopy, and use of protecting stoma were not significant variables, but average age, median tumor height, and method of detection (clinical vs. radiologic) showed significance to explain heterogeneity in anastomotic leak rates. Year of publication, study origin, average age, and use of laparoscopy were significant, but median tumor height and preoperative radiation use were not significant in explaining heterogeneity among observed postoperative death rates. With multivariable analysis, only average age for anastomotic leak and year of publication for postoperative death remained significant.Benchmark complication rates for radical rectal cancer surgery were obtained for use in sample size calculations in future studies and for quality control purposes. Postoperative death rates showed improvement in recent years.