A simple technique to remove a large object from the rectum.
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Adult↗
Biomedical subjects
Santhat Nivatvongs
Publications and source records attributed to Santhat Nivatvongs.
Management of T1 carcinoma of the lower third rectum.
The earliest invasive carcinoma of colon and rectum is an invasion into the submucosa. For the TNM classification, these lesions are T1 Nx Mx. They present as an adenoma with invasive carcinoma, or a frank carcinoma. Local excision for T1 carcinoma of the rectum can be curative if the lesion is accessible for an adequate excision and if the lesion has not spread to the lymph nodes or distant metastasis. The key to success in local excision is selecting the lesions that have low risk of metastasis.
Carcinoma↗
Immediate radical resection after local excision of rectal cancer: an oncologic compromise?
PURPOSE: Local excision for early-staged rectal cancers is controversial. Preoperative understaging is not uncommon and radical resection after local resection may be needed for a curative treatment. The aim of this study was to determine the frequency and outcome of radical resection (within 30 days) after local excision for rectal adenocarcinoma. METHODS: All locally excised rectal cancers (curative intent) that required radical surgery within 30 days were reviewed (1980-2000). T2-3N0-1 stage cancers were each matched to three primary radical surgery controls for stage, age (+/- 5 years), gender, date (+/- 1 years), and type (abdominoperineal resection or low anterior resection) of operation. T1N0-1 cancers were compared with stage-matched rectal cancers treated by either primary radical surgery (n = 78) or local excision alone (n = 77). RESULTS: Fifty-two locally excised rectal adenocarcinomas (29 transanal and 23 polypectomies) were followed by radical surgery (24 abdominoperineal resection and 28 low anterior resection) within 7 (range, 1-29) days. Radical surgery was performed because of a cancerous polyp (n = 42), positive margins (5), lymphovascular invasion (3), and T3-staged cancer (2). Twelve of 52 cancers (23 percent) were found to have nodal involvement and 15 of 52 (29 percent) showed residual cancer in the resected specimen. The T2-3N0-1 stage controls were well matched. No significant difference in tumor location, size, adjuvant therapy, or length of follow-up was noted. Local and distant recurrence occurred in 2 of 4 T2-3N1 tumors and in 2 of 11 T2-3N0 cancers and were comparable to the matched controls, as was survival, with the exception of shorter survival in T3N1 cases, but numbers were too small for a definitive conclusion. Length of follow-up was not different. For T1 cancers, the controls were also comparable regarding patient and tumor demographics and adjuvant therapy. Nodal involvement was 21 percent in T1 study cases and 15 percent in T1 primary radical-surgery controls, with a trend toward location in the lower third of the rectum in both groups (58 percent and 50 percent, respectively). Local recurrence rates were 3 percent in the study group, 5 percent for patients undergoing primary radical surgery, and 8 percent for local excision alone. Distant metastasis (11 percent, 12 percent, and 13 percent, respectively) and overall five-year survival were also not significantly different (78 percent, 89 percent, and 73 percent, respectively). CONCLUSIONS: Nodal involvement in attempted locally excised rectal cancers is not uncommon. Local excision of rectal tumors followed by radical surgery within 30 days in cancer patients does not compromise outcome compared with primary radical surgery. Even after radical surgery for superficial T1 rectal cancers, recurrence rates are not insignificant. Future improvements in preoperative staging may be helpful in selecting tumors for local excision only.
Adenocarcinoma↗
Long-term survival after local excision for T1 carcinoma of the rectum.
PURPOSE: Many authors have reported high rates of local recurrence after local excision for early carcinoma of the rectum, which raises the question of whether oncologic resection gives better results. This study was designed to compare the long-term recurrence rate, long-term survival, and risk factors for T1 adenocarcinoma of the rectum treated with local excision or oncologic resection. METHODS: We identified 144 patients who had T1 sessile adenocarcinoma in the lower third or middle third of the rectum. Patients who received adjuvant therapy or who had pedunculated lesions were excluded. Data included age, gender, size of lesion, histologic type of carcinoma, grade, presence of lymphovascular invasion, and depth of invasion. Outcomes were defined as five-year and ten-year cumulative probabilities of local recurrence, distant metastasis, overall survival, and cancer-free survival. The mean follow-up was 9.2 years; median follow-up was 8.1 years. RESULTS: We compared 70 patients who underwent local excision with 74 patients who underwent oncologic resection. Among patients with lesions in the middle or lower third of the rectum, 1) the five-year and ten-year outcomes were significantly better for overall survival and cancer-free survival in the oncologic resection group, but there were no significant differences in local recurrence or distant metastasis; 2) the multivariate risk factors for long-term, cancer-free survival were invasion into the lower third of the submucosa, local excision, and older than aged 68 years; and 3) for lesions with invasion into the lower third of the submucosa, the oncologic resection group had lower rates of distant metastasis and better survival. Among patients with lesions in the lower third of the rectum, 1) the five-year and ten-year outcomes showed no significant differences in survival, local recurrence, or distant metastasis between the two groups; and 2) for lesions with invasion into the lower third of the submucosa, the oncologic resection group showed a trend of improved survival, which was not statistically significant, possibly because of low statistical power from the small sample size. CONCLUSIONS: Patients who undergo local excision or oncologic resection for T1 carcinoma in the lower two-thirds of the rectum have a high incidence of local recurrence and distant metastasis. To improve the cure rate, the rate of recurrence must decrease. A randomized, controlled study is needed to determine whether adjuvant therapy may be beneficial.
Adenocarcinoma↗
Colorectal adenocarcinoma in cirrhotic patients.
BACKGROUND: Colorectal carcinoma in cirrhotic patients is different from that in patients without the liver disease. The aims of this study were to evaluate the incidence of liver metastasis, postoperative mortality, and the predictors of longterm survival. STUDY DESIGN: A retrospective analysis of patients operated on for colorectal adenocarcinoma at the Mayo Clinic, Rochester, MN between 1976 and 2001, with confirmed liver cirrhosis at the time of abdominal exploration. RESULTS: Seventy-two patients were available for analysis. They were 43% Child A, 42% Child B, and 15% Child C. The median age was 70 (range 42 to 89) years, and the mean duration of followup was 46 months. Postoperative death was 13%. The risk factors were an elevated bilirubin (p = 0.01) and prolonged prothrombin time (p = 0.009). Seven patients (10%) developed liver metastases. For the whole group 1-, 3-, and 5-year survival rates were 69%, 49%, and 35%, respectively. Child A patients had a significantly better survival rate than the combined group of Child B and C patients (p = 0.008). The risks for longterm survival were decreased albumin (p = 0.002) and prolonged prothrombin time (p < 0.001). TNM stage of the carcinoma provided no prognostic information (p = 0.51). CONCLUSIONS: Liver metastases from colorectal adenocarcinoma is infrequent (10%) in cirrhotic patients. The Child's classification, and not the TNM stage of the carcinoma, predicts the risk of postoperative death and longterm survival.
Adenocarcinoma↗
Risk of lymph node metastasis in T1 carcinoma of the colon and rectum.
PURPOSE: Several recent reports of high local recurrence and lymph node metastasis in T1 carcinoma of the rectum prompted us to study the risk factors for lymph node metastasis in these lesions. METHODS: We reviewed the clinical records of 7,543 patients who underwent operative treatment for carcinoma of the colon and rectum from 1979 to 1995. Only patients with sessile T1 lesions who underwent colorectal resection were included in the study, yielding an analysis cohort of 353 patients. The following carcinoma-related variables were assessed: size, mucinous subtype, carcinomatous component, grade, site in colon and rectum, lymphovascular invasion, and depth of submucosal invasion. For the depth, the submucosa was divided into upper third (sm1), middle third (sm2), and lower third (sm3). Chi-squared tests and logistic regression were used to evaluate the variables as potential risk factors for lymph node metastasis. RESULTS: The incidence of T1 lesions was 8.6 percent. In the analysis cohort, the lymph node metastasis rate was 13 percent. Significant predictors of lymph node metastasis both univariately and multivariately were sm3 (P = 0.001), lymphovascular invasion (P = 0.005), and lesions in the lower third of the rectum (P = 0.007). Poorly differentiated carcinoma was significant univariately (P = 0.001) but not in the multivariate model. No other parameter was associated with a significant risk. CONCLUSIONS: T1 colorectal carcinomas with lymphovascular invasion, sm3 depth of invasion, and location in the lower third of the rectum have a high risk of lymph node metastasis. These lesions should have an oncologic resection. In a case of the lesion in the lower third of the rectum, local excision plus adjuvant chemoradiation may be an alternative.
Adenocarcinoma↗
Surgical management of malignant colorectal polyps.
The anatomic landmarks of the depth of invasion for pedunculated lesions (Haggitt level) and the Sm system for the sessile lesions give excellent objective information in the management of malignant colorectal polyps. Malignant polyps with low risk of lymph node metastasis include pedunculated lesions with invasion into Haggitt levels 1, 2, and 3. Level 4 pedunculated lesions and sessile lesions in which the invasion is into Sm1 or Sm2 level also have low risk if there are no adverse factors. These lesions can be treated by a complete local excision. Lesions that have high risk of lymph node metastasis are those with invasion into the lower third of the submucosa (Sm3), lesions that contain lymphovascular invasion, and lesions sited in the lower third of the rectum. These lesions require an oncologic colorectal resection. For lesions in the distal third of the rectum, a per anal full-thickness excision followed by an adjuvant chemoradiation may be an alternative. The box below summarizes malignant colorectal polyps requiring oncologic bowel resections:
Adenoma↗