Surgical Treatment of Recurrent Disease

Local recurrence of rectal carcinoma is a great challenge for a surgeon. Contrary to the majority of other locally recurrent tumours in the digestive system, it is possible to radically remove locally recurrent rectal cancer. Based on results from a number of different Authors [47-49], 5-year survival after re-resection is 2-13% of all patients, with locally recurrent cancer, both alone and associated with distant metastases, we can say that the goals of this kind of surgery are: palliation of symptoms, a good quality of life and, if possible, cure with low treatment-related complication rate.

The ideal goal of salvage surgery is to accomplish en bloc R0 resection, if it is technically feasible and safe. Palliation can also be a very important goal of re-resection, preferably without extensive surgical procedures, unless disabling complications of sepsis or bleeding are an issue.

The decision for salvage surgery should be made on the basis of:

• Patients general health - the patient should be fit enough for potentially extensive surgery.

• Necessary surgical expertise should also be avail-

able for these operations, which should be undertaken in specialised centres where a multidiscipli-nary team is available [41]. The most important thing in this matter is to decide when not to operate. The first and most obvious contraindication for surgery is "frozen pelvis", the condition where recurrent tumour involves all structures of the minor pelvis, including the pelvic walls. The next contraindication is clinical or CT evidence of invasion of the pelvic nerves, lymphatics or veins, or ureter bilaterally (as indicated by the presence of sciatic pattern of pain, unilateral swelling of the lower limb and bilateral hydronephrosis, respectively). Also, evidence of involvement of the lateral pelvic sidewalls and/or upper sacral marrow, and/or S2 is an absolute contraindication for surgery [8].

Every surgical procedure begins with an explorative laparotomy. Peritoneal seeding, unexpected liver metastases and invasion of para-aortic lymph nodes are, in general, contraindications for continuing with a procedure. It is recommended to avoid injury of critical structures before the decision on resectability is made.

Pelvic recurrences are usually amenable to resection if they are strictly anterior or posterior. Lateral sidewall involvement diminishes a chance for R0 resection, as well as involvement of two pelvic walls simultaneously (fixation degree F2). Recurrent tumour that occurs below S2 level is amenable to resection by distal sacrectomy; unfortunately, the existence of tumour in this location usually excludes R0 resection. Similarly, unilateral tumour involvement of blood vessels distal to the aorta may be resectable; bilateral affection of these structures with the recurrent tumour is a contraindication for radical resection. When prostate or base of the bladder are minimally adherent to the recurrent tumour and have good function, it is preferable to attempt combined external-beam radiotherapy (EBRT) with infu-sional 5-FU, followed by organ-preserving resection and intraoperative radiotherapy (IORT). The alternative to this is pelvic exenteration. In cases of more advanced disease and the existence of severe postoperative and post-irradiational adhesions, this cannot be avoided.

Another downside of surgery for recurrent rectal tumour is the problem of intestinal continuity. It is rarely possible or reasonable to create another anastomosis in the kind of surroundings that are at high risk of another relapse. In some series of patients treated for local recurrence [50], up to 93% of them ended up with permanent colostomy. Nevertheless, sometimes, in highly motivated patients with favourable local findings (mucosal anastomotic recurrence), it is possible to perform a low colo-anal anastomosis. To perform a low anterior resection with anastomosis, in these situations moderate doses of pre-operative EBRT and chemotherapy are needed. Unfortunately, usually, a previous low AR is being converted to an APR, and previous APR to an abdominosacral resection or pelvic exenteration.

If at the end of resection it is decided that postoperative EBRT in needed, vascular clips should be placed in the area of peritumoral fibrosis or residual tumour tissue [51].

Extensive procedures employed in the treatment of local recurrence carry significant risk. Patients suffer significant blood loss, morbidity and mortality, and longer hospital stays and operative times. Postoperative complications also occur: infectious disease (sepsis, intra-abdominal abscess, enteric fistula, wound infection), urinary disease (fistulous communications with other organs, stenosis, anastomotic leak) and bowel obstruction [52]. The incidence of complications after abdominosacral resection, for example, according to some Authors, is higher than 80%. The most common are: perineal wound complication (48%) and urinary retention/incontinence, followed by peritonitis, pneumonia, pyelonephritis and different fistulous communications [53]. Mortality rates after these complicated procedures are less than 5% [8].

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