Locally advanced rectal cancer : aspects on management, outcome and reconstruction
Authors: Bolmstrand Björn 
Published: September 2024

<p dir="ltr">Surgical resection with a clear margin remains the mainstay of curative intent therapy for locally advanced primary rectal cancer (LARC). To meet this end extended resection beyond the planes of total mesorectal excision (TME) may be required. As part of multimodality treatment, performed at expert centres, it has been demonstrated to offer potential cure and long-term survival although associated with substantial postoperative morbidity. Population-based outcome data and comparative studies on reconstructive measures are scarce.<br><br>Paper I compared survival in rectal cancer requiring surgery beyond TME (bTME) to that after standard TME on a national population-based level. All patients operated in Sweden between 2009-2018 with anterior resection, abdominoperineal excision (APE) or Hartmann’s procedure for non-metastatic rectal cancer, clinically staged as T3-T4 were included. To account for extent of resection, bTME was subclassified into bTME- and bTME+. Relative survival was inferior after bTME compared to standard TME. Unexpectedly this difference was largely attributable to inferior survival in the group operated bTME with limited extent (bTME-).<br><br>In paper II 189 consecutive patients operated at a single centre between 2004- 2015 with resection and reconstruction of part of the urinary tract in the setting of colorectal and anal malignancy were retrospectively assessed for urological complications. Severe urological complications (Clavien-Dindo >II) amounted to 22% and were more common among patients operated with ureter resection compared to after cystectomy. Irradiation and intestinal anastomotic dehiscence were identified as risk factors for severe urological complications.<br><br>Paper III aimed to compare gluteal flaps to the vertical rectus abdominis myocutaneous (VRAM) flap in terms of perineal wound healing after extralevator APE (ELAPE) for rectal cancer. Some 246 patients operated at two Scandinavian referral centres between 2011-2021 were retrospectively assessed. At three months, the crude risk of incomplete perineal healing was more than doubled among patients operated with gluteal flaps compared to after VRAM flap reconstruction (43.6% vs. 19.8%). A significant association remained after adjustment for comorbidity, smoking, radiotherapy and extent of surgery.<br><br>In paper IV a surgical method using gluteal flaps for combined perineo-vaginal reconstruction after APE with partial vaginectomy for anorectal malignancy was presented and evaluated. The study included 34 consecutive female patients operated between 2005-2017. Assessment based on chart review (n=34), questionnaires (n=14) and clinical examination (n=7) revealed a high perineo-vaginal complication rate and substantial impairment in postoperative sexual function.<br><br>I. Survival after surgery beyond Total Mesorectal Excision for primary locally advanced rectal cancer, a population-based study. B. Bolmstrand, PJ. Nilsson, S. Eloranta, A. Martling, C. Buchli, G. Palmer. European Journal of Surgical Oncology. [Accepted]<br><br>II. Patterns of complications following urinary tract reconstruction after multivisceral surgery in colorectal and anal cancer. B. Bolmstrand, PJ. Nilsson, T. Holm, C. Buchli, G. Palmer. European Journal of Surgical Oncology. 2018; 44: 1513-1517. <a href="https://doi-org/10.1016/j.ejso.2018.06.017" rel="noreferrer" target="_blank">https://doi-org/10.1016/j.ejso.2018.06.017<br></a><br>III. The vertical rectus abdominis myocutaneous flap or versions of gluteal flaps for perineal reconstruction after extralevator abdominoperineal excision for rectal cancer, a comparative cohort study of perineal wound healing and early complications. B. Bolmstrand, PJ Nilsson, A. Bodilsen, G. Palmer. [Manuscript]<br><br>IV. Vaginal reconstruction using a gluteal transposition flap after abdominoperineal excision for anorectal malignancy. B. Bolmstrand, P. Sommar, PJ. Nilsson, D. Zach, J. Lagergren, D. Schain, A. Martling, T. Holm, G. Palmer. Updates in Surgery. 2022; 74: 467-478. <a href="https://doi-org/10.1007/s13304-021-01211-3" rel="noreferrer" target="_blank">https://doi-org/10.1007/s13304-021-01211-3</a></p>