Johnny Chau1,2, Joshua Solomon1, A Sender Liberman1,2, Patrick Charlebois1,2, Barry Stein1,2, Lawrence Lee3,4. 1. Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. 2. Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada. 3. Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. larry.lee@mcgill.ca. 4. Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada. larry.lee@mcgill.ca.
Abstract
BACKGROUND: High-quality surgery is essential for optimal oncologic outcomes in rectal cancer, but total mesorectal excision (TME) can be difficult for mid- and low rectal cancers. Preoperative identification of patients at risk for difficult TME may change the operative approach. The objective of this study was to determine if MRI pelvimetry can predict poor-quality surgery in patients undergoing laparoscopic low anterior resection (LAR) for mid- and low rectal cancer. METHODS: All patients undergoing laparoscopic LAR for rectal cancer ≤ 9 cm from the anal verge at a single tertiary care referral center from 2011 to 2017 were retrospectively reviewed. Pelvic dimensions were measured from preoperative staging MRI on sagittal and axial views. Pelvimetry variables were all dichotomized based on median values. Exploratory factor analysis then identified the most relevant variables for regression analysis. The primary outcome was poor-quality resection, defined as an incomplete mesorectal grade, or involved circumferential (CRM) or distal (DRM) resection margins. RESULTS: There were 92 patients included in this study, of which 70% were male, the mean BMI was 26.0 kg/m2, and the mean tumor height was 6.6 cm. Preoperative (chemo)radiotherapy was administered in 70%, and the pathologic T-stage was T3/T4 in 41%. The overall incidence of poor-quality resection was 17%, including 13% incomplete TME, 7% involved CRM, and 1% involved DRM. Factor analysis identified S1-pubic symphysis and the angle between S1 and S5-bottom of symphysis (angle ABD) as relevant variables. After adjusting for pathologic T-stage, BMI, and tumor height, a S1-S5-bottom of symphysis angle > 74.3° (OR 6.19, 95% CI 1.18-32.37) independently predicted poor-quality resection. CONCLUSIONS: MRI pelvimetry can identify patients at risk for a poor-quality resection after laparoscopic proctectomy for mid- and low rectal cancer. These patients may benefit from the selective use of more advanced access methods to improve surgical resection quality.
BACKGROUND: High-quality surgery is essential for optimal oncologic outcomes in rectal cancer, but total mesorectal excision (TME) can be difficult for mid- and low rectal cancers. Preoperative identification of patients at risk for difficult TME may change the operative approach. The objective of this study was to determine if MRI pelvimetry can predict poor-quality surgery in patients undergoing laparoscopic low anterior resection (LAR) for mid- and low rectal cancer. METHODS: All patients undergoing laparoscopic LAR for rectal cancer ≤ 9 cm from the anal verge at a single tertiary care referral center from 2011 to 2017 were retrospectively reviewed. Pelvic dimensions were measured from preoperative staging MRI on sagittal and axial views. Pelvimetry variables were all dichotomized based on median values. Exploratory factor analysis then identified the most relevant variables for regression analysis. The primary outcome was poor-quality resection, defined as an incomplete mesorectal grade, or involved circumferential (CRM) or distal (DRM) resection margins. RESULTS: There were 92 patients included in this study, of which 70% were male, the mean BMI was 26.0 kg/m2, and the mean tumor height was 6.6 cm. Preoperative (chemo)radiotherapy was administered in 70%, and the pathologic T-stage was T3/T4 in 41%. The overall incidence of poor-quality resection was 17%, including 13% incomplete TME, 7% involved CRM, and 1% involved DRM. Factor analysis identified S1-pubic symphysis and the angle between S1 and S5-bottom of symphysis (angle ABD) as relevant variables. After adjusting for pathologic T-stage, BMI, and tumor height, a S1-S5-bottom of symphysis angle > 74.3° (OR 6.19, 95% CI 1.18-32.37) independently predicted poor-quality resection. CONCLUSIONS: MRI pelvimetry can identify patients at risk for a poor-quality resection after laparoscopic proctectomy for mid- and low rectal cancer. These patients may benefit from the selective use of more advanced access methods to improve surgical resection quality.
Entities:
Keywords:
Laparoscopy; MRI; Pelvimetry; Proctectomy; Quality resection; Rectal cancer
Authors: Pere Planellas; Helena Salvador; Lídia Cornejo; Maria Buxó; Ramon Farrés; Xavier Molina; Albert Maroto; Núria Ortega; Jose Ignacio Rodríguez-Hermosa; Antoni Codina-Cazador Journal: Langenbecks Arch Surg Date: 2020-11-27 Impact factor: 3.445