الفهرس 
Anatomy of the Colon, Rectum
Internal Anal Sphincter (IAS):Only 14 pages are availabe for public view
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Abstract
Colorectal cancer has gradually become one of the most significant leading
causes of death from malignancies worldwide, surgical management is still the
mainstay of the treatment.
The role of laparoscopic resection in the management of rectal cancer is now
widely accepted following several large randomized controlled trials. Neoadjuvant
chemoradiotherapy for rectal cancer has been shown to considerably reduce tumor
size, produce downstaging of the T stage resulting in reduced postoperative local
recurrence, increased sphincter saving surgery in low rectal cancer and improved
postoperative survival however, tissue edema and fibrosis caused by
chemoradiotherapy can hamper the dissection of the tissue also, mist and exudates
can block the surgeon’s vision and cause challenging difficulties during laparoscopic
rectal resections that may affect the oncological and short term postoperative
outcomes.
This study was conducted over a period from October 2014 to February 2017 on
30 patients with rectal carcinoma who underwent laparoscopic rectal resections after
nCRT, 16 males (53.3%) and 14 females (46.7%).
The patients’ ages ranged between 26 and 68 years with the mean age 48.63
±12.53 years and a median of 51.5 years. The BMI ranged between 24 and 45
kg/m2, with a mean of 33 ± 5.72 kg/m2 and median of 45 kg/m2. Nineteen patients
(63.3%) had an (ASA) class (I), 8 patients (26.7 %) had ASA class (II) and 3
patients (10.0%) had ASA class (III). Eleven patients (36.7%) had co-morbidities
and five patients (16.7%) had previous abdominal operations. No patient had history
of anorectal trauma or fecal incontinence. One patient had history of
haemorrhoidectomy.According to laparoscopic surgical procedures carried out, 19 patients
(63.3%) underwent laparoscopic low anterior resection and 11 patients (36.7%)
underwent laparoscopic abdominoperineal resection.
The operative time for LLAR ranged between 150 and 220 minutes with a
mean of 180.79 ± 22.00 min and a median of 180 min while, the operative time for
LAPR ranged between 160 and 240 minutes with a mean of 202.73 ± 24.12 and with
a median of 200 min. In LLAR group the mean blood loss was 66.05 ± 31.60 cc
with a median of 55 cc and for LAPR group it was 241.82 ± 101.37 cc with a
median of 250 cc. Adverse events occurred during laparoscopic procedures in 7
patients (23.3%) including one instance of left uretric injury which was repaired
intraoperatively, another patient had injury to the left gonadal vessels that was
clipped, another male patient had right vas deferens injury, injury of the
membranous urethra occurred during perineal dissection in one male patient that
was identified and repaired during surgery, injury of the IMA occurred in one
patient and was controlled by Ligasure, uncontrollable intra-abdominal bleeding
during retroperitoneal dissection occurred in one patient that required conversion to
open technique and defective colorectal anastomosis after firing of the circular
stapler that was repaired intraoperatively. One patient in LLAR resection group
(5.3%) was converted to open surgery to repair injured left ureter and another patient
in the LAPR group (9.1%) was converted to open surgery to control unexplained
bleeding during retroperitoneal dissection.
The duration of analgesia usage ranged from 1-3 days in LLAR group with a
mean of 1.58±0.69 days and a median of 1 day and ranged between 2-7 days in
LAPR group with a mean 3.82±1.33 days and a median of 4 days. As regard to first
time of bowel motion, it ranged between 1-4 days with a mean of 1.32±0.75 days
and a median of 1 day in LLAR group and with a mean of 1.64±1.03 days and a
median of 1 day for LAPR group. First time of oral intake ranged between 8-24 hours with a mean of 19.368 ± 4.631 hours and a median of 8 hours in LLAR group
and with a mean of 26.181 ± 9.031 hours and a median of 8 hours in LAPR group.
Hospital stay ranged between 4 and 10 days in LLAR group with a mean of
5.63±1.3 days and a median of 5 days. In LAPR group, it ranged from 5-15 days
with a mean of 8.18±3.37 days and a median of 7 days
As regard postoperative complications, in LLAR group, 2 patients (10.5%)
developed Pfannenstiel wound infection. In abdominoperineal resection group,
perineal wound infection followed by wound dehiscence occurred in 2 patients
(18.1%). In LLAR group, 1 patient (5.3%) developed postoperative ileus, while 2
patients (18.2%) in LAPR group developed postoperative ileus. Postoperative
pulmonary embolism occurred in one patient (9.1%) of LAPR group. Urinary fistula
developed in one patient (5.3%) of LLAR group. Anastomotic stricture developed in
one patient of LLAR group (5.3%) who had transanal hand sewn colo-anal
anastomosis. Sexual dysfunction in the form of weak erections occurred in 1 patient
of LLAR group (5.3%), and in 2 patients in the LAPR group (18.2%). Local
recurrence occurred in one patient (9.1%) in the LAPR group. In LAPR group, one
patient (9.1%) presented with parastomal hernia. One patient in LAPR group (9.1%)
died one month PO due to massive pulmonary embolism.
The proximal resection margin ranged between 7-19 cm with a mean of
12.20±2.95 cm and a median of 12 cm that was free of malignant infiltration in all
patients. The distal resection margin (DRM) ranged between 1-4 cm with a mean of
2.23±0.65 cm and a median of 2 cm and was free of malignant infiltration in all
patients. The circumferential resection margin was infiltrated in the 2 patients
(6.7%) with T4 tumours.
Three patients (10.0%) showed pathological complete response after nCRT The number of retrieved lymph nodes ranged between 8-14 with a mean of 10.57±1.74 lymph node and a median of 11 lymph nodes. Fifteen patients (50.0%)
show positive lymph nodes metastasis.
The results showed that laparoscopic resection for rectal carcinoma after
nCRT is technically feasible, oncologically safe and poses the benefits of the short
term outcomes of laparoscopy like less analgesia, early return of bowel functions
and short hospital stay with favourable overall morbidity and mortality.