title: Routine defunctioning stoma after chemoradiation and total mesorectal excision: a single-surgeon experience.
abstract: OBJECTIVE
  To investigate the 10-year results of treating low rectal cancer by a single surgeon in one institution.
  
  
  METHODS
  From Oct 1998 to Feb 2009, we prospectively followed a total of 62 patients with cT2-4 low rectal cancer with lower tumor margins measuring at 3 to 6 cm above the anal verge. All patients received neoadjuvant chemoradiation (CRT) for 6 wk. Among them, 85% of the patients received 225 mg/m(2)/d 5-fluorouracil using a portable infusion pump. The whole pelvis received a total dose of 45 Gy of irradiation in 25 fractions over 5 wk. The interval from CRT completion to surgical intervention was planned to be approximately 6-8 wk. Total mesorectal excision (TME) and routine defunctioning stoma construction were performed by one surgeon. The distal resection margin, circumferential resection margin, tumor regression grade (TRG) and other parameters were recorded. We used TRG to evaluate the tumor response after neoadjuvant CRT. We evaluated anal function outcomes using the Memorial Sloan-Kettering Cancer Center anal function scores after closure of the defunctioning stoma.
  
  
  RESULTS
  The median distance from the lower margin of rectal cancer to the anal verge was 5 cm: 6 cm in 9 patients, 5 cm in 32 patients, 4 cm in 10 patients, and 3 cm in 11 patients. Before receiving neoadjuvant CRT, 45 patients (72.6%) had a cT3-4 tumor, and 21 (33.9%) patients had a cN1-2 lymph node status. After CRT, 30 patients (48.4%) had a greater than 50% clinical reduction in tumor size. The final pathology reports revealed that 33 patients (53.2%) had a ypT3-4 tumor and 12 (19.4%) patients had ypN1-2 lymph node involvement. All patients completed the entire course of neoadjuvant CRT. Most patients developed only Grade 1-2 toxicities during CRT. Thirteen patients (21%) achieved a pathologic complete response. Few post-operative complications occurred. Nearly 90% of the defunctioning stomas were closed within 6 mo. The local recurrence rate was 3.2%. Pathologic lymph node involvement was the only prognostic factor predicting disease recurrence (36.5% vs 76.5%, P = 0.006). Nearly 90% of patients recovered sphincter function within 2 year after closure of the defunctioning stoma.
  
  
  CONCLUSIONS
  Neoadjuvant CRT followed by TME, combined with routine defunctioning stoma construction and high-volume surgeon experience, can provide excellent surgical quality and good local disease control.
authors.affiliation: Division of Colorectal Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan.
authors.forename: Shao-Chieh
authors.initials: SC
authors.lastname: Lin
authors.forename: Po-Chuan
authors.initials: PC
authors.lastname: Chen
authors.forename: Chung-Ta
authors.initials: CT
authors.lastname: Lee
authors.forename: Hong-Ming
authors.initials: HM
authors.lastname: Tsai
authors.forename: Peng-Chan
authors.initials: PC
authors.lastname: Lin
authors.forename: Helen H W
authors.initials: HH
authors.lastname: Chen
authors.forename: Yuan-Hwa
authors.initials: YH
authors.lastname: Wu
authors.forename: Bo-Wen
authors.initials: BW
authors.lastname: Lin
authors.forename: Wen-Pin
authors.initials: WP
authors.lastname: Su
authors.forename: Jenq-Chang
authors.initials: JC
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D000964:Antimetabolites, Antineoplastic / Q000008:administration & dosage; D059186:Chemoradiotherapy, Adjuvant / Q000009:adverse effects / Q000401:mortality; D003125:Colostomy / Q000009:adverse effects; D019583:Dose Fractionation, Radiation; D004334:Drug Administration Schedule; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D005500:Follow-Up Studies; D006785:Hospitals, University; D006801:Humans; D007081:Ileostomy / Q000009:adverse effects; D007262:Infusions, Intravenous; D053208:Kaplan-Meier Estimate; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000009:adverse effects / Q000401:mortality; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D054047:Surgical Stomas / Q000009:adverse effects; D013624:Taiwan; D013997:Time Factors; D016896:Treatment Outcome; D047368:Tumor Burden
chemical_list: D000964:Antimetabolites, Antineoplastic; D005472:Fluorouracil
keywords: Defunctioning stoma; Neoadjuvant chemoradiation; Pathologic complete response; Rectal cancer; Total mesorectal excision
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