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IntroductionTotal mesorectal excision (TME) is the standard procedure for middle lower rectal cancer, and transanal total mesorectal excision (taTME) was founded as a valid alternative to the open and laparoscopic TME. The quality of the procedure performed is important for prognosis of patients. This study was designed to compare the pathological results of taTME with those of laparoscopic TME (laTME), based on the data from a randomized control trial (RCT: NCT02966483).MethodsBetween April 2016 and November 2018, all rectal cancer patients who underwent taTME or laTME in the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) and enrolled in the RCT were included in this study. The data from all participants were prospectively input in a standardized database.ResultsIn total 128 patients were included in the taTME group and 133 patients were included in the laTME group. The demographics and tumor characteristics were not significantly different between the two group. T3 or N0 lesions were most common in both groups. The mesorectum specimen was complete or nearly complete in all patients. The positive distal resection margin (DRM) was detected in 2 (1.5%) cases in the laTME group versus no cases in the taTME group (P = 0.498), and the distance between the tumor and DRM in the taTME group (1.4 ± 1.1) may have the longer tendency than that in the laTME group (1.3 ± 0.9) (P = 0.745). The positive circumferential resection margin was detected in 2 cases in each group (P = 0.674). The median number of resected lymph nodes was 15.0 in taTME group versus 16.0 in the laTME group (P = 0.069).ConclusionThe pathological outcomes between transanal and laparoscopic total mesorectal excision are similar. The rate of positive resection margin could not be significant decreased, nonetheless the decrease trend could be shown.

Background It is generally accepted that the distal resection margin of intermediate- to low-lying rectal cancer should be greater than 2 cm and at least 1 cm in special cases. This study intends to investigate whether a distal resection margin ≤ 1 cm affects tumor outcomes for patients with intermediate- to low-lying rectal cancer. Methods A systematic review of the literature was conducted. Sixteen studies included data for distal resection margins ≤ 1 cm (1684 cases) and > 1 cm (5877 cases), and 5 studies included survival data. Meta-analysis was used to compare the local recurrence rate and long-term survival of patients with distal resection margins > or ≤ 1 cm. Results The local recurrence rate in the ≤ 1-cm margin group (9.5%) was 2.3% higher than that in the > 1-cm margin group (7.2%) according to a fixed-effects model (RR [95% CI ] 1.42 [1.18, 1.70], P  < 0.001). The overall survival results of the five 1-cm margin studies showed an HR (95% CI ) of 0.96 (0.75, 1.24) ( P  = 0.78). Subgroup analysis showed that the local recurrence rate in the subgroup with perioperative treatment was 1.2% lower in the ≤ 1-cm margin group (8.3%) than in the > 1-cm margin group (9.5%) ( RR [95% CI ] 0.97 [0.63, 1.49], P  = 0.90). In the surgery alone subgroup, the local recurrence rate was 4.7% higher in the ≤ 1-cm margin group (12.4%) than in the > 1-cm group (7.7%) ( RR [95% CI ] 1.76 [1.09, 2.83], P  = 0.02). Conclusions For patients with intermediate- to low-lying rectal cancer undergoing surgery alone, a distal resection margin ≤ 1 cm may be not safe.

Aim The optimal distal resection margin (DRM) for rectal neuroendocrine tumors (NETs) remains unclear. Although rectal NETs are generally considered indolent, aggressive resection may compromise anorectal function. This study aimed to investigate whether shorter DRM affects recurrence risk in patients with rectal NETs undergoing curative resection. Methods This retrospective study included 208 patients with rectal NETs who underwent total mesorectal excision (TME) at a single institution between January 2005 and December 2023. The patients were categorized into two groups based on DRM length: shorter DRM (SDRM) (≤ 10 mm) and longer DRM (LDRM) (> 10 mm). Clinicopathological characteristics, recurrence patterns, and survival outcomes were compared between the groups. A fine‐grey regression model was used to identify independent predictors of recurrence. Results Among the 208 patients, 91 (43.8%) had a short DRM. There was no significant difference in the overall recurrence rate between the SDRM and LDRM groups (6.6% vs. 6.0%, p = 1.000), and no local recurrence was reported in either group. In multivariate analysis, tumor size > 20 mm (hazard ratio [HR], 7.01; p = 0.008) and NET G2 (HR, 5.18; p = 0.03) were independent risk factors for recurrence, whereas a short DRM was not. Five‐year overall recurrence and survival rates did not differ between the groups. Conclusions In rectal NETs, SDRM may not increase the risk of recurrence when R0 resection is achieved. While oncological radicality should remain the highest priority, minimizing DRM may be oncologically safe and could support more function‐preserving surgery, particularly for rectal NET G1/G2. This study evaluated the impact of distal resection margin (DRM) length on recurrence in 208 patients undergoing surgery for rectal neuroendocrine tumors (NETs). Our findings demonstrate that while oncological safety must unquestionably remain the top priority, a short pathological DRM (< 10 mm) does not increase recurrence risk when R0 resection is achieved, supporting more tailored, function‐preserving surgical approaches for rectal NETs.

Purpose Recently, common application of sphincter-saving resection in rectal cancer has led to acceptance of a 1-cm distal resection margin (DRM). The aim of this study was to evaluate oncologic outcomes of a DRM ≤1 cm in sphincter-saving resection for rectal cancer. The outcomes of a DRM ≤0.5 cm was also evaluated. Methods We reviewed prospectively collected data from 415 patients who underwent sphincter-saving resection for mid and low rectal cancer between September 2006 and December 2012 at Korea University Anam Hospital. Patients were divided into two groups according to DRM measured in a formalin fixed specimen: ≤1 cm ( n  = 132) and >1 cm ( n  = 283). The DRM ≤1 cm group was divided into two subgroups: ≤0.5 cm ( n  = 45) and >0.5, ≤1 cm ( n  = 87). Results Median follow-up periods were 47.2 months. The 5-year local recurrence rate was 8.8% in the DRM ≤1 cm group and 8.5% in the DRM >1 cm group ( p  = 0.630). The 5-year disease-free survival rate was 75.1 and 76.3% ( p  = 0.895), and the 5-year overall survival rate was 82.6 and 85.9% ( p  = 0.401), respectively. In subanalysis of the DRM ≤1 cm group, there was also no significant difference in the local recurrence and survival. Conclusions There was no significant difference in local recurrence and survival based on DRM length. We found that DRM length less than 1 cm was not a prognostic factor for local recurrence or survival.

Background Reduced-port laparoscopic surgery is the latest innovation in minimally invasive surgery. We performed single-incision plus one additional port laparoscopy-assisted anterior resection (SILS + 1-AR) starting in August 2010. This study aimed at evaluating the feasibility of SILS + 1-AR and comparing it with that of conventional laparoscopy-assisted anterior resection (C-AR). Methods Patients with preoperative clinical stage 0 to stage III rectal cancer were included. Demographic, intraoperative, and pathological examination data, as well as short-term outcome data, of 20 patients who underwent SILS + 1-AR were retrospectively compared with that of 20 patients who underwent C-AR. Invasiveness of the two procedures was also evaluated through a vital signs diary and hematological examination on postoperative days (POD) 1, 3, and 7. Results Operating time, mean estimated blood loss, the number of lymph nodes dissected, the number of lymph node metastases, and the mean distal resection margin length were not significantly different. However, postoperative neutrophil counts in the SILS + 1-AR group were lower than those in the C-AR group ( P  = 0.085). A significant difference in body temperature was observed in the SILS + 1-AR group on POD 1 ( P  = 0.028). No significant differences were observed in perioperative and overall morbidity between the two groups. Conversion to open surgery was required in 2 (10 %) of the 20 patients in the SILS + 1-AR group. The mean postoperative length of stay and recurrence rates were similar in the two groups. Conclusion SILS + 1-AR for rectal cancer is similar to C-AR in safety, feasibility, and provision of oncological radicality.

Introduction The distal resection margin (DRM) has been considered an important factor for the oncological outcome of rectal cancer surgery. However, the optimal distal margins required to achieve safe oncological outcome remains to be controversial. Material and methods More recently, as circumferential resection margin or mesorectal margin has been additionally reported to be more important factors predicting patient outcome than the distal mucosal margin, a re-evaluation of the impact of DRM on patient outcome is needed. Results The extent of distal tumor spread is known to be influenced by a variety of factors such as tumor location, lymph node metastasis, and tumor size. DRM might affect survival more than a local recurrence. Because distal intramural tumor spread rarely exceeds 1 to 2 cm in most rectal cancers, and local control and survival do not seem to be compromised by shorter distal resection margins, the generally accepted practice is to aim for a 2-cm DRM. However, in the recent trend of curative resection after preoperative chemoradiotherapy, with an otherwise favorable tumor such as well-differentiated tumor and no lymph node metastasis, a DRM at ≤1 cm does not necessarily portend a poor prognosis. In cases with preoperative chemoradiotherapy, distal resection margins need to be evaluated individually. Discussion It has been suggested that down-staging of low-lying rectal cancers after preoperative radiation might well include the pathological clearance of distal intramural microscopic spread. Moreover, the measurement of DRM varies with respective study, making it difficult to compare. Conclusion We need an applicable intraoperative method to accurately measure distal resection margin, enabling comparative outcome.

Low recurrence rates and long term survival are the main therapeutic goals of rectal cancer surgery. Complete, margin- negative resection confers the greatest chance for a cure. The aim of our study was to determine whether the length of the distal resection margin was associated with local recurrence rate and long- term survival. One hundred and nine patients, who underwent sphincter-preserving resection for locally advanced rectal cancer after preoperative chemoradiotherapy between 2006 and 2010 in two tertiary referral centres were included in the study. Distal resection margin lengths were measured on formalin-fixed, pinned specimens. Characteristics of patients with distal resection margin < 8 mm (Group I, n = 27), 8-20 mm (Group II, n = 31) and > 20 mm (Group III, n = 51) were retrospectively analysed and compared. Median (range) follow-up time in Group I was 89 (51-111), in Group II 83 (57-111) and in Group III 80 (45-116) months (p = 0.326), respectively. Univariate survival analysis showed that distal resection margin length was not statistically significantly associated with overall survival or local recurrence rate (p > 0.05). In a multiple Cox regression analysis, after adjusting for pathologic T and N stage (yT, yN), distal resection margin length was still not statistically significantly associated with overall survival. Our study shows that close distal resection margins can be accepted as oncologically safe for sphincter-preserving rectal resections after preoperative chemoradiotherapy.

Background Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility, the functional outcome, and the short-term oncologic outcomes of laparoscopic ISR for low rectal adenocarcinoma at our institution. Methods We retrospectively reviewed the data of 111 consecutive patients who underwent laparoscopic ISR for low rectal adenocarcinoma between July 2005 and December 2009. Demographic status, surgical outcomes, functional outcome data, and oncologic outcome data were collected. Results The mean distance of the tumor from the anal verge was 3.4 cm (range: 1–5 cm). The mean operative time was 214.7 min (range, 150–450 min). The mean distal resection margin was 1.3 ± 1.1 cm. Morbidity occurred in 24 patients (21.6%), including anastomotic leakage in 2 patients (1.8%). The mean Wexner continence score after stoma repair was 7.5 ± 2.7 (range: 2 ~ 19), and 9.8 in total ISR, 7.3 in partial ISR ( P  = 0.071). The 3-year overall survival rate was 92.8%, and the 3-year disease-free survival rate was 73.0%. Local recurrence was noted in 6 of the 111 patients with TNM stage I to III (5.4%). The patients with lesions at 2 cm to the dentate line had a 7.07-fold greater risk of local recurrence, including a 13.42-fold greater risk of lateral pelvic wall recurrence and perineal recurrence (95% Confidence interval [CI], 1.141–158.006; P  = 0.009) than in those who had lesions more than 2 cm from the anal verge (95% CI, 1.290–38.832; P  = 0.011). Conclusions Laparoscopic ISR after neoadjuvant chemoradiation can be recommended as a technically feasible, minimally invasive, and a sphincter-saving procedure with acceptable functional and short-term oncologic outcomes in patients with very low rectal cancer.

Background The required distal margin in partial mesorectal excision (PME) is controversial. The aim of this systematic review was to determine incidence and distance of distal mesorectal spread (DMS). Methods A systematic search was performed using PubMed, Embase and Google Scholar databases. Articles eligible for inclusion were studies reporting on the presence of distal mesorectal spread in patients with rectal cancer who underwent radical resection. Results Out of 2493 articles, 22 studies with a total of 1921 patients were included, of whom 340 underwent long-course neoadjuvant chemoradiotherapy (CRT). DMS was reported in 207 of 1921 (10.8%) specimens (1.2% in CRT group and 12.8% in non-CRT group), with specified distance of DMS relative to the tumor in 84 (40.6%) of the cases. Mean and median DMS were 20.2 and 20.0 mm, respectively. Distal margins of 40 mm and 30 mm would result in 10% and 32% residual tumor, respectively, which translates into 1% and 4% overall residual cancer risk given 11% incidence of DMS. The maximum reported DMS was 50 mm in 1 of 84 cases. In subgroup analysis, for T3, the mean DMS was 18.8 mm (range 8–40 mm) and 27.2 mm (range 10–40 mm) for T4 rectal cancer. Conclusions DMS occurred in 11% of cases, with a maximum of 50 mm in less than 1% of the DMS cases. For PME, substantial overtreatment is present if a distal margin of 5 cm is routinely utilized. Prospective studies evaluating more limited margins based on high-quality preoperative magnetic resonance imaging and pathological assessment are required.

Zusammenfassung Die Therapiestrategien beim Rektumkarzinom umfassen je nach Tumorausdehnung die primäre operative Resektion oder beim lokal fortgeschrittenen Karzinom die neoadjuvante (Radio‑)Chemotherapie ([R]CTx) bzw. total neoadjuvante Therapie (TNT) in der Regel gefolgt von der chirurgischen Therapie. Bei der Resektion gilt es, die Balance zwischen Radikalität und Funktionserhalt zu finden. Aktuelle Zahlen zeigen, dass bei neoadjuvant behandelten Patienten geringere Sicherheitsabstände ohne Beeinträchtigung des onkologischen Outcomes möglich sind. Dies ermöglicht bei Patienten mit tiefsitzenden Karzinomen ggf. eine kontinenzerhaltende Operation. Insbesondere in diesen Fällen spielt die intraoperative Schnellschnittdiagnostik zur Bestätigung der tumorfreien Absetzungsränder eine zentrale Rolle. Aber auch bei der transanalen Abtragung früher Karzinome oder bei der operativen Resektion von Rektumkarzinomrezidiven nimmt die Schnellschnittdiagnostik eine wichtige Rolle ein. Sie sollte allerdings nicht routinemäßig, sondern gezielt bei spezifischer Fragestellung und entsprechender therapeutischer Konsequenz erfolgen. Die Aussagekraft der Schnellschnittdiagnostik beim neoadjuvant behandelten Rektumkarzinom kann eingeschränkt sein, sodass die abschließende Bewertung des Resektionsstatus und damit die Festlegung der weiteren Therapie anhand der fixierten Paraffinschnitte erfolgen muss.