Tech Coloproctol DOI 10.1007/s10151-014-1251-8
CORRESPONDENCE
Re: Staying on Target—reply to comments by Loyal et al. J. D. Foster • N. J. Smart • N. K. Francis
Received: 13 November 2014 / Accepted: 14 November 2014 Ó Springer-Verlag Italia Srl 2015
Dear Sir, We would like to thank Doctors Loyal and Bergamaschi for their interest in our article [1]. We wholeheartedly agree with their statement that one of the primary goals of any rectal cancer resection procedure should be to minimise the rate of positive circumferential resection margin (CRM) tumour involvement. As we stated in the article, the most important oncological part of the ELAPE procedure, the dissection in the region of the tumour, is carried out via the perineal dissection and therefore should not be substantially influenced by the adoption of a laparoscopic approach to the abdominal and mesorectal dissection. It is interesting, however, that amongst those patients with lower third rectal cancers operated as part of the COLOR II trial, there was a reduced rate of CRM involvement in the laparoscopic arm [2]; it might be inferred from this that the magnified, illuminated views of the pelvis offered by laparoscopy may enable the surgeon to better define the optimal extent of dissection that should be performed from the abdominal approach. We agree that it may have been theoretically feasible to have performed a less radical intra-sphincteric dissection for some of the tumours in our series that were staged as T2 and have clearly acknowledged this within the article. This highlights the challenge presented to radiologists when trying to declare whether a low rectal tumour lies entirely within the rectum or whether its outer border abuts the adjacent musculature, especially in thinner patients with minimal adipose tissue at the tapering distal extent of the J. D. Foster N. K. Francis (&) Yeovil District Hospital, Yeovil, Someset, UK e-mail: [email protected] N. J. Smart Royal Devon and Exeter NHS Trust, Exeter, Devon, UK
mesorectum. Where such clarity is lacking, careful discussion with the individual patient rather than a dogmatic approach seems a prudent strategy. Similarly, whilst early reports of outcomes following ELAPE showed very low CRM involvement rates [3], more recent series have reported much higher rates of 20 to 24 % [4, 5]. Whilst this may in part relate to variations in the application of the surgical technique, one wonders could this also reflect variation in multi-disciplinary team decision making? Under-staging of a tumour may result in a surgeon attempting ELAPE for a tumour that crosses the plane of dissection where a more radical exenteration procedure may have been the optimal procedure. With the introduction of new, or as in this case revisited, surgical techniques, we feel strongly that careful prospective audit is essential to ensure that the hypothesised benefits of the procedure are realised. This is especially true where level 1 evidence is not yet available, as in the case of ELAPE. Whilst the results of REAP and other ongoing multi-centre trials are awaited to provide further evidence for the oncological superiority of ELAPE, it remains our opinion that combining this technique with a laparoscopic approach to the abdominal and mesorectal dissection can offer further benefits to patients without compromising these oncological benefits. Yours faithfully, Jake Foster, Neil Smart, Nader Francis Conflict of interest
None.
References 1. Kipling SL, Young K, Foster JD et al (2014) Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series. Tech Coloproctol 18:445–451
123
Tech Coloproctol 2. van der Pas MH, Haglind E, Cuesta MA et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218 3. West NP, Anderin C, Smith KJ et al (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97:588–599
123
4. Palmer G, Anderin C, Martling A, Holm T (2014) Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer. Colorectal Dis 16:527–532 5. Bondeven P, Laurberg S, Hagemann-Madsen RH, Ginnerup Pedersen B (2014) Suboptimal surgery and omission of neoadjuvant therapy for upper rectal cancer is associated with a high risk of local recurrence. Colorectal Dis. doi:10.1111/codi.12869
CORRESPONDENCE
Re: Staying on Target—reply to comments by Loyal et al. J. D. Foster • N. J. Smart • N. K. Francis
Received: 13 November 2014 / Accepted: 14 November 2014 Ó Springer-Verlag Italia Srl 2015
Dear Sir, We would like to thank Doctors Loyal and Bergamaschi for their interest in our article [1]. We wholeheartedly agree with their statement that one of the primary goals of any rectal cancer resection procedure should be to minimise the rate of positive circumferential resection margin (CRM) tumour involvement. As we stated in the article, the most important oncological part of the ELAPE procedure, the dissection in the region of the tumour, is carried out via the perineal dissection and therefore should not be substantially influenced by the adoption of a laparoscopic approach to the abdominal and mesorectal dissection. It is interesting, however, that amongst those patients with lower third rectal cancers operated as part of the COLOR II trial, there was a reduced rate of CRM involvement in the laparoscopic arm [2]; it might be inferred from this that the magnified, illuminated views of the pelvis offered by laparoscopy may enable the surgeon to better define the optimal extent of dissection that should be performed from the abdominal approach. We agree that it may have been theoretically feasible to have performed a less radical intra-sphincteric dissection for some of the tumours in our series that were staged as T2 and have clearly acknowledged this within the article. This highlights the challenge presented to radiologists when trying to declare whether a low rectal tumour lies entirely within the rectum or whether its outer border abuts the adjacent musculature, especially in thinner patients with minimal adipose tissue at the tapering distal extent of the J. D. Foster N. K. Francis (&) Yeovil District Hospital, Yeovil, Someset, UK e-mail: [email protected] N. J. Smart Royal Devon and Exeter NHS Trust, Exeter, Devon, UK
mesorectum. Where such clarity is lacking, careful discussion with the individual patient rather than a dogmatic approach seems a prudent strategy. Similarly, whilst early reports of outcomes following ELAPE showed very low CRM involvement rates [3], more recent series have reported much higher rates of 20 to 24 % [4, 5]. Whilst this may in part relate to variations in the application of the surgical technique, one wonders could this also reflect variation in multi-disciplinary team decision making? Under-staging of a tumour may result in a surgeon attempting ELAPE for a tumour that crosses the plane of dissection where a more radical exenteration procedure may have been the optimal procedure. With the introduction of new, or as in this case revisited, surgical techniques, we feel strongly that careful prospective audit is essential to ensure that the hypothesised benefits of the procedure are realised. This is especially true where level 1 evidence is not yet available, as in the case of ELAPE. Whilst the results of REAP and other ongoing multi-centre trials are awaited to provide further evidence for the oncological superiority of ELAPE, it remains our opinion that combining this technique with a laparoscopic approach to the abdominal and mesorectal dissection can offer further benefits to patients without compromising these oncological benefits. Yours faithfully, Jake Foster, Neil Smart, Nader Francis Conflict of interest
None.
References 1. Kipling SL, Young K, Foster JD et al (2014) Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series. Tech Coloproctol 18:445–451
123
Tech Coloproctol 2. van der Pas MH, Haglind E, Cuesta MA et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218 3. West NP, Anderin C, Smith KJ et al (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97:588–599
123
4. Palmer G, Anderin C, Martling A, Holm T (2014) Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer. Colorectal Dis 16:527–532 5. Bondeven P, Laurberg S, Hagemann-Madsen RH, Ginnerup Pedersen B (2014) Suboptimal surgery and omission of neoadjuvant therapy for upper rectal cancer is associated with a high risk of local recurrence. Colorectal Dis. doi:10.1111/codi.12869
