Is It Worth Performing Inter-Sphincteric Resection in Patients Having Rectal Adenocarcinoma with Oligo-Metastasis: A Study Of 416 Patients.

Is It Worth Performing Inter-Sphincteric Resection in Patients Having Rectal Adenocarcinoma with Oligo-Metastasis: A Study Of 416 Patients. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Is It Worth Performing Inter-Sphincteric Resection in Patients Having Rectal Adenocarcinoma with Oligo-Metastasis: A Study Of 416 Patients. Abdeali Saif Arif Kaderi, Sanjay Singh, Ankit Sharma, Mufaddal Kazi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4369611/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Inter-sphincteric resection (ISR) is being increasingly performed in metastatic rectal adenocarcinoma (with oligo-metastasis) patients. There has been a trend towards worse prognosis in this group. This study compares the oncological and surgical outcomes of patients with and without pre-operative oligo-metastasis who underwent ISR. The outcomes compared include prognostic factors like margin positivity, recurrence rates, stoma reversal rate, surgical failure rate (defined as a combination of one or more of the aforestated factors). The demographic pattern, American Society of anaesthesia grade (ASA), treatment received, clinical and histopathological T and N stage, grade, type of MIS approach, neoadjuvant therapy and pathological high-risk features are also studied. Methods: Patients who underwent minimally invasive ISR over ten years at a high-volume tertiary cancer centre were selected for the study. Factors used for the assessment of oncological outcomes were margin positivity (circumferential resection and distal margin), recurrence (both local and systemic) and stoma reversal rate. A descriptive and comparative analysis were performed. Results: Four hundred and eight patients underwent minimally invasive ISR of which 25 (6.12%) patients were oligo-metastatic. Higher recurrence (24% versus 18.5%) and low stoma reversal rate (36.8% versus 67.3%) were observed in the oligo-metastatic group with statistically significant differences. Though no local recurrence was seen in the oligometastatic group the difference was not statistically different. Margin positivity was the same in both groups. Conclusion: This study shows that oligometastatic patients who underwent ISR experienced higher recurrence and low stoma reversal rates without affecting margin positivity. Intersphincteric resection Oligometastatic ISR Stoma non-reversal permanent stoma. Introduction Intersphincteric resection (ISR)[ 1 ] is a well-established sphincter saving procedure for low rectal cancers where intersphincteric space is free and not suitable for stapled anastomosis. While the outcome of locally advanced rectal cancers depends on local recurrence, and disease-free survival (DFS), stoma reversal is an important endpoint of sphincter-saving procedure. 15–20 per cent of ISR/ low anterior resection (LAR) do not undergo reversal due to anastomotic complications or distant metastasis despite locoregional control. This situation gets more complicated in oligometastatic disease, who undergo either synchronous or metachronous resections[ 2 ], [ 3 ], [ 4 ], [ 5 ],[ 6 ]. At what point stoma reversal would fit in between these procedures is difficult While the oncological outcomes of metastatic diseases have validated the performance of major resections in landmark series[ 7 ], the quality of life needs to be given equal if not more importance, due to the improved survival. However, permanent stoma avoidance, which was the necessity for this invention, itself became its Achilles heel. The aim of this study is to study the oncological and surgical outcomes of patient undergoing ISR who had oligometastatic disease with non-metastatic cases. A composite end point viz. surgical failure was defined as margin positivity rate, recurrence rate and stoma reversal rate or a combination of these was evaluated. Functional sphincter preservation is pivotal in the surgical outcomes of ultra-low anterior resection and ISR. A significant proportion of patients undergoing ISR have incontinence[ 8 ] resulting in technically permanent diversion stomas[ 9 ]. Similarly, patients with intact sphincters and early recurrences (3.4%)[ 9 ] lose the chance of stoma reversal. We studied the oncological and quality of life outcomes in oligometastatic low rectal cancers who underwent ISR to compare the outcomes with non-metastatic counterparts and appraise the futility of performing ISR in metastatic cases. Methods Patients, Setting, Design This is a single institution retrospective study. Consecutive patients who underwent minimally invasive (MIS) and open ISR over the period of January 2013to March 2024 at a high-volume tertiary cancer centre were selected for the study. Patients of all age groups and metastases status were included. Variables and outcomes Electronic medical records of these patients were reviewed and prognostic factors like margin positivity (circumferential resection and distal margin), recurrence (both local and systemic) and stoma reversal rate were noted. Surgical failure was defined as any or a combination of positive margin, local recurrence and stoma non-reversal rates. The demographic pattern, American Society of anaesthesia grade (ASA), treatment received, clinical and histopathological T and N stage, grade, type of MIS approach, neoadjuvant therapy and pathological high-risk features were recorded. Statistics Continuous variables were represented by medians and interquartile range and group comparisons were performed using the Mann-Whitney U test. Similarly, categorical variables were represented by numbers and proportions, while comparisons were performed using the Chi-squared test. A p value of < 0.05 was considered of significance. All statistical analyses were conducted using Microsoft Office Excel version 2019 and IBM SPSS version 25 (IBM Co., Armonk, NY, USA). Ethics The study protocol was designed and conducted in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki Declaration and its later amendments. Because the study was retrospective and used anonymized data without patient contact, the institutional research board waived the need for approval. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results Four hundred and sixteen patients underwent minimally invasive ISR. Out of these, metastatic versus non metastatic information was not available for 8 patients. Thus, the final analysis was performed on four hundred and eight patients. The age, sex ratio, ASA grade and body mass index (BMI) were comparable in both groups. Similarly, oncological factors like histological grades, clinical T and N stage, extramural vascular invasion (EMVI), and type of MIS approach were comparable. The surgical outcomes viz. circumferential resection margins (CRM), and distal recurrence margins (DRM) were comparable. Similarly, the oncological outcome viz. local recurrence was comparable. 25 (6.12%) patients were having pre-operative oligo-metastasis and the rest (93.88%) were non-metastatic. Consequently, the oligometastatic group had a higher proportion of patients receiving neoadjuvant chemotherapy. A higher recurrence of 24% (6 out of 25 patients) and a low stoma reversal rate of 36.8% were observed in the oligo-metastatic group with a statistically significant difference compared to 67.3% stoma reversal rate and a 18.5% (71 out of 383) recurrence rate in the non-metastatic group. Though no local recurrence was seen in the oligometastatic group the difference was not statistically different. However, the overall recurrence was higher in the oligometastatic group (24%% versus 18.5%) with a p value of 0.499. Finally, surgical failure was seen in 148 patients (38.7%) % (4% CRM positive, 2.9% distal margin positive, 11.5% pelvic recurrence and 32.7% stoma non reversal rate) in the non-metastatic group and 13 patients (52%) (5% CRM positive and 63.2% stoma non reversal rate in the oligometastatic group (p 0.009). The demographic factors and the outcome factors are summarised in Table 1 . Table 1 Demographic and outcome factors comparing 408 patients non-metastatic and metastatic patients undergoing Intersphincteric resection (ISR) over 11 years. Metastases Variable Categories Without pre-operative metastasis (383) With pre-operative oligometastasis (25) Total P value Age Median (IQR) 47 (37–56) 45 (40–56) 47 (37–56) 0.999 Pre-operative Albumin Median (IQR) 4.1 (3.8–4.3) 4 (3.49–4.095) 4.07 (3.8–4.3) 0.017 Body mass index (BMI) Median (IQR) 23.835 (21.575–25.9625) 23.27 (20.5–25.4) 23.8 (21.5–25.93) 0.547 Serum CEA Median (IQR) 3.4 (2–6.3) 4.6 (2.75–10) 3.4 (2.07–6.5) 0.034 Surgery duration Median (IQR) 300 (250–372.5) 350 (240–450) 300 (245–377.5) 0.175 Blood loss Median (IQR) 250 (200–400) 400 (325–1100) 250 (200–400) 0.000 Sex Female 112 (29.2) 11 (44) 123 (30.1) 0.119 Male 271 (70.8) 14 (56) 285 (69.9) Total 383 (100) 25 (100) 408 (100) ECOG performance status 0 4 (1) 0 (0) 4 (1) 0.681 1 323 (84.3) 20 (80) 343 (84.1) 2 56 (14.6) 5 (20) 61 (15) Total 383 (100) 25 (100) 408 (100) ASA 1 219 (57.3) 15 (60) 234 (57.5) 0.820 2 154 (40.3) 9 (36) 163 (40) 3 9 (2.4) 1 (4) 10 (2.5) Total 382 (100) 25 (100) 407 (100) Preoperative T stage T1 5 (1.3) 0 (0) 5 (1.2) 0.087 T2 73 (19.3) 6 (24) 79 (19.6) T3 273 (72.2) 14 (56) 287 (71.2) T4 25 (6.6) 4 (16) 29 (7.2) Tis 2 (0.5) 1 (4) 3 (0.7) Total 378 (100) 25 (100) 403 (100) Preoperative N stage N0 91 (23.9) 4 (16) 95 (23.5) 0.009 N1 185 (48.7) 7 (28) 192 (47.4) N2 104 (27.4) 14 (56) 118 (29.1) Total 380 (100) 25 (100) 405 (100) Neoadjuvan ttherapy No 49 (12.9) 2 (8) 51 (12.6) 0.477 Yes 332 (87.1) 23 (92) 355 (87.4) Total 381 (100) 25 (100) 406 (100) NACTRT No 91 (23.9) 13 (52) 104 (25.7) 0.002 Yes 289 (76.1) 12 (48) 301 (74.3) Total 380 (100) 25 (100) 405 (100) Surgery ISD 4 (1) 2 (8) 6 (1.5) 0.019 ISR 375 (98.4) 23 (92) 398 (98) PISR 2 (0.5) 0 (0) 2 (0.5) Total 381 (100) 25 (100) 406 (100) LVI (Lympho-vascular invasion) No 358 (95.5) 23 (92) 381 (95.3) 0.430 Yes 17 (4.5) 2 (8) 19 (4.8) Total 375 (100) 25 (100) 400 (100) PNI (Perineural invasion) No 361 (96.3) 23 (92) 384 (96) 0.292 Yes 14 (3.7) 2 (8) 16 (4) Total 375 (100) 25 (100) 400 (100) EMVI (Extramural vascular invasion) No 359 (95.7) 24 (96) 383 (95.8) 0.949 Yes 16 (4.3) 1 (4) 17 (4.3) Total 375 (100) 25 (100) 400 (100) Number of positive nodes Nodes negative 273 (73.6) 12 (50) 285 (72.2) 0.012 Nodes positive 98 (26.4) 12 (50) 110 (27.8) Total 371 (100) 24 (100) 395 (100) Circumferential resection margin Negative 361 (96) 24 (96) 385 (96) 0.998 Positive 15 (4) 1 (4) 16 (4) Total 376 (100) 25 (100) 401 (100) Distal Margin CRM 23 (6) 1 (4) 24 (5.9) 0.625 No 349 (91.1) 24 (96) 373 (91.4) Yes 11 (2.9) 0 (0) 11 (2.7) Total 383 (100) 25 (100) 408 (100) Peritoneal recurrence No 196 (93.8) 12 (85.7) 208 (93.3) 0.243 Yes 13 (6.2) 2 (14.3) 15 (6.7) Total 209 (100) 14 (100) 223 (100) Pelvic recurrence No 184 (88.5) 14 (100) 198 (89.2) 0.178 Yes 24 (11.5) 0 (0) 24 (10.8) Total 208 (100) 14 (100) 222 (100) Recurrence in liver No 193 (92.8) 8 (57.1) 201 (90.5) 0.000 Yes 15 (7.2) 6 (42.9) 21 (9.5) Total 208 (100) 14 (100) 222 (100) Recurrence in lung No 193 (92.8) 12 (85.7) 205 (92.3) 0.335 Yes 15 (7.2) 2 (14.3) 17 (7.7) Total 208 (100) 14 (100) 222 (100) Recurrence in retroperitoneal nodes No 193 (91.9) 14 (100) 207 (92.4) 0.268 Yes 17 (8.1) 0 (0) 17 (7.6) Total 210 (100) 14 (100) 224 (100) Anastomosis stricture No 220 (80.3) 15 (93.8) 235 (81) 0.182 Yes 54 (19.7) 1 (6.3) 55 (19) Total 274 (100) 16 (100) 290 (100) Anal dilatation No 154 (79.8) 10 (90.9) 164 (80.4) 0.366 Yes 39 (20.2) 1 (9.1) 40 (19.6) Total 193 (100) 11 (100) 204 (100) Stoma reversal No 116 (32.7) 12 (63.2) 128 0.006 Yes 355 (67.3) 7 (36.8) 362 Discussion Our study aimed to understand the percentage of patients with oligometastatic disease who underwent ISR. Furthermore, we analyzed what percentage of these patients underwent stoma reversal and compared that with the non-metastatic group. Oligometastatic disease needs additional adjuvant chemotherapy and ancillary procedures. Thus, the time point suitable for stoma reversal is a logistic concern. On average, the adjuvant chemotherapy starts 3–4 weeks after the surgery and lasts for 6–9 months. Whether stoma closure should be done during the chemotherapy or after completion of chemotherapy is a matter of debate and personal preference. ISR offers a combination of surgical as well as well as oncological outcomes. Our series has a local recurrence of 6.1% in the non-metastatic group and none in the oligometastatic group in congruence with the contemporary groups. [ 10 ][ 11 ] .The margin positivity rate was 3% in non-metastatic group and nil in oligometastatic group. This is comparable to close margin rates in the contemporary series[ 10 ] of 3.2%. In our previously published series of 310 patients undergoing ISR, the surgical failure was seen in 21% of patients. Out of these, positive margin was seen in 3.5%, local recurrence in 5.8% and an unreversed stoma in 17%. A higher number (n = 12, 12%) of systemic recurrences were seen in the preoperative M1 patients[ 12 ]. In another series of 142 patients published by our group, comprising of poorly differentiated and signet ring cell tumors(PDSR), local recurrence was seen in 15.6% in in the PDSR group and 11.7% in the non-PDSR group and the difference was not significant[ 13 ]. Only tumor stage and not the histology was a predictor of recurrence. The treatment algorithms have been reviewed time and again and the treatment sequence is based on the whether the primary is symptomatic and metastasis is resectable. A large series 92 patients of CRLM from our institute has 22 patients undergoing LAR/ISR as a part of simultaneous resection. Although it demonstrated feasibility of simultaneous proctectomy with liver resection, rectal carcinomas, especially undergoing ISR have been under-represented in most of the series[ 14 ]. None of the series explore this aspect of treatment planning in rectal carcinoma with oligometastases to the best of our knowledge. Having a stoma significantly affects day to day life of patients and some show reluctance to even temporary stomas to the extent that they refuse curative surgery. Social embarrassment and body image are major issues faced by patients with stoma. To avoid such such predicament, a proper counselling of stoma care is of utmost importance[ 15 ]. Older age, ASA score > 2, comorbidities, open surgery, surgical complications, anastomotic leakage, stage IV tumor, and local recurrence have been reported as risk factors for non-closure of defunctioning stomas after anal preservation surgery in one meta-analysis[ 16 ]. Patients with these risk factors need to be informed preoperatively of the possibility of non-reversal. [ 17 ]. [ 18 ]. [ 19 ]. A retrospective study from South Korea reported tumor progression with local and systemic recurrence as a cause of permanent stoma[ 20 ]. This study recognised the relevance of metastatic status. It was found that metastatic cases had higher chances of permanent stoma (hazard ratio (HR), 3.380; 95% confidence interval (CI), 1.192–18.023; p = 0.027) In a retrospective study[ 21 ] of low anterior resection, 12% of stoma were not reversible, 11% required a repeat stoma after stoma closure and 10% received a late permanent stoma. The risk factor identified were male gender, low tumor site, advanced stage and anastomotic complications. Despite the reduction in recurrences over the past decade, the rate of permanent stoma did not change. One center from Seoul[ 22 ] reported anastomotic complication (7 out of 71 permanent stoma) to be the primary cause of early permanent stoma and recurrence (27 out of 71 permanent stoma) to be the cause of late permanent stoma. Yet another group[ 23 ] from Korea reported a series of 2528 patients who underwent surgery for low rectal cancers and had 28 out of 231 patients having permanent stoma due to either anastomotic leak or recurrence. Thus, metastatic status has been less recognised as a risk factor for stoma non-reversal. These studies have very small number of metastatic Ca rectum who underwent ISR, and thus cannot identify all the predictors of successful reversal. A higher number of cases of this subgroup is needed to conclusively prove the same. It may be inferred from these studies that doing ISR in metastatic Ca rectum is not without risks. Hence, patients must be chosen more carefully for ISR in metastatic setting. There isn’t compelling evidence to preclude ISR in metastatic cases. A clear lesson learnt from this analysis is that patients must be explained about the chances of non-reversal. Our study is not without limitations. It is a single- center retrospective study. The surgical failure was assessed in terms of local recurrence, persistent stoma rates and margin positivity. However, functional outcomes in term of sphincter tone, incontinence rates and low anterior resection scores were not recorded. Furthermore, ours is a group of robotic and laparoscopic ISR, hence the effects are blended and the heterogeneity in terms of surgical failure caused by adopting either approach is not well demarcated. A short-term follow-up of the recently operated group is another limitation hence part of our data is in the preliminary phase. Follow-up is going on and is expected to give mature results. Conclusion This study shows that the patients who undergo ISR with pre-operative oligo metastasis experience higher recurrence and low stoma reversal rates without affecting margin positivity. It is a prerequisite to carefully counsel the patient as regards the chances of a permanent stoma in such scenarios. The patients’ expectations may not be met if the early disease recurrence hampers stoma reversal in oligometastatic cases. Hence, higher than usual chances of a stoma non-reversal must be acceded by the patient while consenting for this procedure. Since the number of patients with oligo-metastasis is very low in the present study, a larger sample size is required to translate this conjecture into evidence. Statements and declarations The authors have no competing interests and funding to declare. Author contributions: Avanish Saklani contributed to study conception and design. Material preparation, data collection and analysis was performed by Abdeali Saif Arif Kaderi, Ankit Sharma and Sanjay Singh. The first draft of manuscript was written by Abdeali Saif Arif Kaderi. Mufaddal Kazi and Avanish Saklani commented on previous versions of the manuscript. All authors read and approved the final manuscript. Compliance and ethical standards: No conflicts of interest to disclose. This research was a retrospective study of already existing data of human participants Ethics committee was approached and waiver of consent was taken for this retrospective study. No funding was received for conducting this study. References R. Schiessel, J. Karner-Hanusch, F. Herbst, B. Teleky, and M. Wunderlich, “Intersphincteric resection for low rectal tumours,” Br J Surg , vol. 81, no. 9, pp. 1376–1378, Sep. 1994, doi: 10.1002/bjs.1800810944. R. Adam, A. Laurent, D. Azoulay, D. Castaing, and H. Bismuth, “Two-Stage Hepatectomy: A Planned Strategy to Treat Irresectable Liver Tumors:,” Annals of Surgery , vol. 232, no. 6, pp. 777–785, Dec. 2000, doi: 10.1097/00000658-200012000-00006. F. Calderon Novoa et al. , “Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?,” Cancers , vol. 15, no. 7, p. 2113, Apr. 2023, doi: 10.3390/cancers15072113. W. M. Lo, S. T. Tohme, and D. A. Geller, “Recent Advances in Minimally Invasive Liver Resection for Colorectal Cancer Liver Metastases—A Review,” Cancers , vol. 15, no. 1, p. 142, Dec. 2022, doi: 10.3390/cancers15010142. R. Hernandez-Alejandro, L. I. Ruffolo, R. Alikhanov, B. Björnsson, O. J. M. Torres, and A. Serrablo, “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis,” International Journal of Surgery , vol. 82, pp. 103–108, Oct. 2020, doi: 10.1016/j.ijsu.2020.04.009. E. Al-Sharif, “Portal vein embolization effect on colorectal cancer liver metastasis progression: Lessons learned,” WJCO , vol. 6, no. 5, p. 142, 2015, doi: 10.5306/wjco.v6.i5.142. R. Adam et al. , “Patients With Initially Unresectable Colorectal Liver Metastases: Is There a Possibility of Cure?,” JCO , vol. 27, no. 11, pp. 1829–1835, Apr. 2009, doi: 10.1200/JCO.2008.19.9273. J. Gori et al. , “Comparative study of functional outcomes between ultra‐low anterior resection and inter‐sphincteric resection: a propensity matched analysis,” ANZ Journal of Surgery , vol. 92, no. 1–2, pp. 151–156, Jan. 2022, doi: 10.1111/ans.17405. C.-Y. Kuo et al. , “Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for patients with rectal cancer having undergoing sphincter-saving operation,” Asian Journal of Surgery , vol. 46, no. 5, pp. 1944–1950, May 2023, doi: 10.1016/j.asjsur.2022.09.107. S. P. Puntambekar et al. , “Intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers,” Laparoscopic, Endoscopic and Robotic Surgery , vol. 6, no. 2, pp. 57–62, Jun. 2023, doi: 10.1016/j.lers.2023.04.001. K. Shirouzu, N. Murakami, and Y. Akagi, “Intersphincteric resection for very low rectal cancer: A review of the updated literature,” Annals of Gastroent Surgery , vol. 1, no. 1, pp. 24–32, Apr. 2017, doi: 10.1002/ags3.12003. “2024 ASCRS Annual Scientific Meeting.” Accessed: Apr. 10, 2024. [Online]. Available: https://ascrs24.eventscribe.net/fsPopup.asp?PresentationID=1356883&mode=presInfo A. L. Desouza, M. Kazi, K. Verma, P. Sugoor, B. K. Mahendra, and A. P. Saklani, “Local recurrence with intersphincteric resection in adverse histology rectal cancers. A retrospective study with competing risk analysis,” ANZ Journal of Surgery , vol. 91, no. 11, pp. 2475–2481, 2021, doi: 10.1111/ans.17155. M. Kazi et al. , “Simultaneous resection of synchronous colorectal liver metastasis: Feasibility and development of a prediction model,” Ann Hepatobiliary Pancreat Surg , vol. 27, no. 1, pp. 40–48, Feb. 2023, doi: 10.14701/ahbps.22-043. W. C. Zewude, T. Derese, Y. Suga, and B. Teklewold, “Quality of Life in Patients Living with Stoma,” Ethiop J Health Sci , vol. 31, no. 5, pp. 993–1000, Sep. 2021, doi: 10.4314/ejhs.v31i5.11. X. Zhou, B. Wang, F. Li, J. Wang, and W. Fu, “Risk Factors Associated With Nonclosure of Defunctioning Stomas After Sphincter-Preserving Low Anterior Resection of Rectal Cancer: A Meta-Analysis,” Diseases of the Colon & Rectum , vol. 60, no. 5, pp. 544–554, May 2017, doi: 10.1097/DCR.0000000000000819. G. G. David, J. P. Slavin, S. Willmott, D. J. Corless, A. U. Khan, and C. R. Selvasekar, “Loop ileostomy following anterior resection: is it really temporary?,” Colorectal Disease , vol. 12, no. 5, pp. 428–432, May 2010, doi: 10.1111/j.1463-1318.2009.01815.x. O. Song, K. H. Kim, S. Y. Lee, C. H. Kim, Y. J. Kim, and H. R. Kim, “Risk factors of stoma re-creation after closure of diverting ileostomy in patients with rectal cancer who underwent low anterior resection or intersphincteric resection with loop ileostomy,” Ann Surg Treat Res , vol. 94, no. 4, p. 203, 2018, doi: 10.4174/astr.2018.94.4.203. M. F. Sier, L. van Gelder, D. T. Ubbink, W. A. Bemelman, and R. J. Oostenbroek, “Factors affecting timing of closure and non-reversal of temporary ileostomies,” Int J Colorectal Dis , vol. 30, no. 9, pp. 1185–1192, Sep. 2015, doi: 10.1007/s00384-015-2253-3. S. W. Lim, H. J. Kim, C. H. Kim, J. W. Huh, Y. J. Kim, and H. R. Kim, “Risk factors for permanent stoma after low anterior resection for rectal cancer,” Langenbecks Arch Surg , vol. 398, no. 2, pp. 259–264, Feb. 2013, doi: 10.1007/s00423-012-1038-1. T. Junginger, U. Gönner, T. T. Trinh, A. Lollert, K. Oberholzer, and M. Berres, “Permanent Stoma After Low Anterior Resection for Rectal Cancer,” Diseases of the Colon & Rectum , vol. 53, no. 12, pp. 1632–1639, Dec. 2010, doi: 10.1007/DCR.0b013e3181ed0aae. S. I. Seo et al. , “Characteristics and risk factors associated with permanent stomas after sphincter-saving resection for rectal cancer,” World J Surg , vol. 37, no. 10, pp. 2490–2496, Oct. 2013, doi: 10.1007/s00268-013-2145-z. C. M. Lee et al. , “Risk Factors of Permanent Stomas in Patients with Rectal Cancer after Low Anterior Resection with Temporary Stomas,” Yonsei Med J , vol. 56, no. 2, p. 447, 2015, doi: 10.3349/ymj.2015.56.2.447. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4369611","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308396320,"identity":"8f3537d4-80a4-4ad5-b109-6cb646e70e14","order_by":0,"name":"Abdeali Saif Arif Kaderi","email":"","orcid":"","institution":"Tata Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdeali","middleName":"Saif Arif","lastName":"Kaderi","suffix":""},{"id":308396321,"identity":"59905451-f0ec-4a40-9cab-488d6f022a09","order_by":1,"name":"Sanjay Singh","email":"","orcid":"","institution":"Tata Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sanjay","middleName":"","lastName":"Singh","suffix":""},{"id":308396322,"identity":"a7cf3c9a-c45c-41e4-8f69-728fbb0f12cb","order_by":2,"name":"Ankit Sharma","email":"","orcid":"","institution":"Tata Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ankit","middleName":"","lastName":"Sharma","suffix":""},{"id":308396323,"identity":"cb3a5025-467d-48d0-8bfc-661cd7586f5c","order_by":3,"name":"Mufaddal Kazi","email":"","orcid":"","institution":"Tata Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mufaddal","middleName":"","lastName":"Kazi","suffix":""},{"id":308396324,"identity":"f5f3238d-e73b-4121-a4e8-4c9b7ad79ece","order_by":4,"name":"Ashwin Desouza","email":"","orcid":"","institution":"Tata Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ashwin","middleName":"","lastName":"Desouza","suffix":""},{"id":308396325,"identity":"e798020f-f406-4726-983d-a73ac5a5d385","order_by":5,"name":"Avanish Saklani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie3PsQrCMBCA4ROhLgddI4i+QkqguPkqKUKndHIVEQqOuhZ8CcEXCATTsWtAB1FwFgodi9FVqXVzyD8lcB/JAbhc/1kXzgDok9eFDNoRbkk/g87SEmxNgJoXge/E36gr5fPTgB3T/GLmY4SeOuyaCDEx41zfMDzpKBXafgzj2DQ+Y4BJ7ikMjQhS4VlC7LlJjIq8lLxWyLInqVsQKgXj0UohJZYkqxYkMGJGo7VCu1S0TdYEvW+7DIt8T+6VmvjZVJaiWgz9ntLN67/l/Tbucrlcrk89AH6lSEy/ZaEhAAAAAElFTkSuQmCC","orcid":"","institution":"Tata Memorial Hospital","correspondingAuthor":true,"prefix":"","firstName":"Avanish","middleName":"","lastName":"Saklani","suffix":""}],"badges":[],"createdAt":"2024-05-04 19:53:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4369611/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4369611/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57974739,"identity":"bcc570ab-6ba0-47d6-bfc4-1f073f770982","added_by":"auto","created_at":"2024-06-08 11:19:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":572280,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4369611/v1/6a8d06d5-a576-4f9b-a77c-3e180219af65.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is It Worth Performing Inter-Sphincteric Resection in Patients Having Rectal Adenocarcinoma with Oligo-Metastasis: A Study Of 416 Patients.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntersphincteric resection (ISR)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] is a well-established sphincter saving procedure for low rectal cancers where intersphincteric space is free and not suitable for stapled anastomosis. While the outcome of locally advanced rectal cancers depends on local recurrence, and disease-free survival (DFS), stoma reversal is an important endpoint of sphincter-saving procedure. 15\u0026ndash;20 per cent of ISR/ low anterior resection (LAR) do not undergo reversal due to anastomotic complications or distant metastasis despite locoregional control. This situation gets more complicated in oligometastatic disease, who undergo either synchronous or metachronous resections[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e],[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. At what point stoma reversal would fit in between these procedures is difficult While the oncological outcomes of metastatic diseases have validated the performance of major resections in landmark series[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the quality of life needs to be given equal if not more importance, due to the improved survival. However, permanent stoma avoidance, which was the necessity for this invention, itself became its Achilles heel.\u003c/p\u003e \u003cp\u003eThe aim of this study is to study the oncological and surgical outcomes of patient undergoing ISR who had oligometastatic disease with non-metastatic cases. A composite end point viz. surgical failure was defined as margin positivity rate, recurrence rate and stoma reversal rate or a combination of these was evaluated. Functional sphincter preservation is pivotal in the surgical outcomes of ultra-low anterior resection and ISR. A significant proportion of patients undergoing ISR have incontinence[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] resulting in technically permanent diversion stomas[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Similarly, patients with intact sphincters and early recurrences (3.4%)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] lose the chance of stoma reversal. We studied the oncological and quality of life outcomes in oligometastatic low rectal cancers who underwent ISR to compare the outcomes with non-metastatic counterparts and appraise the futility of performing ISR in metastatic cases.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients, Setting, Design\u003c/h2\u003e \u003cp\u003eThis is a single institution retrospective study. Consecutive patients who underwent minimally invasive (MIS) and open ISR over the period of January 2013to March 2024 at a high-volume tertiary cancer centre were selected for the study. Patients of all age groups and metastases status were included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eVariables and outcomes\u003c/h2\u003e \u003cp\u003eElectronic medical records of these patients were reviewed and prognostic factors like margin positivity (circumferential resection and distal margin), recurrence (both local and systemic) and stoma reversal rate were noted. Surgical failure was defined as any or a combination of positive margin, local recurrence and stoma non-reversal rates. The demographic pattern, American Society of anaesthesia grade (ASA), treatment received, clinical and histopathological T and N stage, grade, type of MIS approach, neoadjuvant therapy and pathological high-risk features were recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eContinuous variables were represented by medians and interquartile range and group comparisons were performed using the Mann-Whitney U test. Similarly, categorical variables were represented by numbers and proportions, while comparisons were performed using the Chi-squared test. A p value of \u0026lt;\u0026thinsp;0.05 was considered of significance. All statistical analyses were conducted using Microsoft Office Excel version 2019 and IBM SPSS version 25 (IBM Co., Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study protocol was designed and conducted in accordance with the ethical standards of\u003c/p\u003e \u003cp\u003e the institutional research committee and the 1964 Helsinki Declaration and its later\u003c/p\u003e \u003cp\u003eamendments. Because the study was retrospective and used anonymized data without\u003c/p\u003e \u003cp\u003e patient contact, the institutional research board waived the need for approval. The study\u003c/p\u003e \u003cp\u003eadhered to the Strengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e \u003cp\u003e (STROBE) guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFour hundred and sixteen patients underwent minimally invasive ISR. Out of these, metastatic versus non metastatic information was not available for 8 patients. Thus, the final analysis was performed on four hundred and eight patients. The age, sex ratio, ASA grade and body mass index (BMI) were comparable in both groups. Similarly, oncological factors like histological grades, clinical T and N stage, extramural vascular invasion (EMVI), and type of MIS approach were comparable. The surgical outcomes viz. circumferential resection margins (CRM), and distal recurrence margins (DRM) were comparable. Similarly, the oncological outcome viz. local recurrence was comparable. 25 (6.12%) patients were having pre-operative oligo-metastasis and the rest (93.88%) were non-metastatic. Consequently, the oligometastatic group had a higher proportion of patients receiving neoadjuvant chemotherapy. A higher recurrence of 24% (6 out of 25 patients) and a low stoma reversal rate of 36.8% were observed in the oligo-metastatic group with a statistically significant difference compared to 67.3% stoma reversal rate and a 18.5% (71 out of 383) recurrence rate in the non-metastatic group. Though no local recurrence was seen in the oligometastatic group the difference was not statistically different. However, the overall recurrence was higher in the oligometastatic group (24%% versus 18.5%) with a p value of 0.499. Finally, surgical failure was seen in 148 patients (38.7%) % (4% CRM positive, 2.9% distal margin positive, 11.5% pelvic recurrence and 32.7% stoma non reversal rate) in the non-metastatic group and 13 patients (52%) (5% CRM positive and 63.2% stoma non reversal rate in the oligometastatic group (p 0.009). The demographic factors and the outcome factors are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and outcome factors comparing 408 patients non-metastatic and metastatic patients undergoing Intersphincteric resection (ISR) over 11 years.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eMetastases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout pre-operative metastasis (383)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWith pre-operative oligometastasis (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (37\u0026ndash;56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (40\u0026ndash;56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47 (37\u0026ndash;56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-operative Albumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 (3.8\u0026ndash;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (3.49\u0026ndash;4.095)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.07 (3.8\u0026ndash;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (BMI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.835 (21.575\u0026ndash;25.9625)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.27 (20.5\u0026ndash;25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.8 (21.5\u0026ndash;25.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum CEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4 (2\u0026ndash;6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.6 (2.75\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4 (2.07\u0026ndash;6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e300 (250\u0026ndash;372.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e350 (240\u0026ndash;450)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e300 (245\u0026ndash;377.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e250 (200\u0026ndash;400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e400 (325\u0026ndash;1100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e250 (200\u0026ndash;400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e123 (30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e271 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e285 (69.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e383 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e408 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG performance status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.681\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e323 (84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e343 (84.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e383 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e408 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e219 (57.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e234 (57.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.820\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154 (40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e163 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e382 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e407 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative T stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e273 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e287 (71.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e378 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e403 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative N stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185 (48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e192 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e118 (29.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e380 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e405 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvan ttherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e332 (87.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e355 (87.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e381 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e406 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNACTRT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e289 (76.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e301 (74.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e380 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e405 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eISD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eISR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e375 (98.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e398 (98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePISR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e381 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e406 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVI (Lympho-vascular invasion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e358 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e381 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e375 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e400 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI (Perineural invasion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e361 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e384 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e375 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e400 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEMVI (Extramural vascular invasion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e359 (95.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e383 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e375 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e400 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of positive nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNodes negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e273 (73.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e285 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNodes positive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e371 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e395 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircumferential resection margin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e361 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e385 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e376 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e401 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal Margin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCRM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e349 (91.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e373 (91.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e383 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e408 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeritoneal recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e196 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e208 (93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e209 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e223 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvic recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e184 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e198 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e222 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence in liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (92.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e201 (90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e222 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence in lung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (92.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e205 (92.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e222 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence in retroperitoneal nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e207 (92.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e224 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomosis stricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e220 (80.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e235 (81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e274 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e290 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnal dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154 (79.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e164 (80.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e204 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStoma reversal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e355 (67.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study aimed to understand the percentage of patients with oligometastatic disease who underwent ISR. Furthermore, we analyzed what percentage of these patients underwent stoma reversal and compared that with the non-metastatic group. Oligometastatic disease needs additional adjuvant chemotherapy and ancillary procedures. Thus, the time point suitable for stoma reversal is a logistic concern. On average, the adjuvant chemotherapy starts 3\u0026ndash;4 weeks after the surgery and lasts for 6\u0026ndash;9 months. Whether stoma closure should be done during the chemotherapy or after completion of chemotherapy is a matter of debate and personal preference.\u003c/p\u003e \u003cp\u003eISR offers a combination of surgical as well as well as oncological outcomes. Our series has a local recurrence of 6.1% in the non-metastatic group and none in the oligometastatic group in congruence with the contemporary groups. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] .The margin positivity rate was 3% in non-metastatic group and nil in oligometastatic group. This is comparable to close margin rates in the contemporary series[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] of 3.2%. In our previously published series of 310 patients undergoing ISR, the surgical failure was seen in 21% of patients. Out of these, positive margin was seen in 3.5%, local recurrence in 5.8% and an unreversed stoma in 17%. A higher number (n\u0026thinsp;=\u0026thinsp;12, 12%) of systemic recurrences were seen in the preoperative M1 patients[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In another series of 142 patients published by our group, comprising of poorly differentiated and signet ring cell tumors(PDSR), local recurrence was seen in 15.6% in in the PDSR group and 11.7% in the non-PDSR group and the difference was not significant[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Only tumor stage and not the histology was a predictor of recurrence.\u003c/p\u003e \u003cp\u003eThe treatment algorithms have been reviewed time and again and the treatment sequence is based on the whether the primary is symptomatic and metastasis is resectable. A large series 92 patients of CRLM from our institute has 22 patients undergoing LAR/ISR as a part of simultaneous resection. Although it demonstrated feasibility of simultaneous proctectomy with liver resection, rectal carcinomas, especially undergoing ISR have been under-represented in most of the series[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. None of the series explore this aspect of treatment planning in rectal carcinoma with oligometastases to the best of our knowledge.\u003c/p\u003e \u003cp\u003eHaving a stoma significantly affects day to day life of patients and some show reluctance to even temporary stomas to the extent that they refuse curative surgery. Social embarrassment and body image are major issues faced by patients with stoma. To avoid such such predicament, a proper counselling of stoma care is of utmost importance[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOlder age, ASA score\u0026thinsp;\u0026gt;\u0026thinsp;2, comorbidities, open surgery, surgical complications, anastomotic leakage, stage IV tumor, and local recurrence have been reported as risk factors for non-closure of defunctioning stomas after anal preservation surgery in one meta-analysis[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Patients with these risk factors need to be informed preoperatively of the possibility of non-reversal. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A retrospective study from South Korea reported tumor progression with local and systemic recurrence as a cause of permanent stoma[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This study recognised the relevance of metastatic status. It was found that metastatic cases had higher chances of permanent stoma (hazard ratio (HR), 3.380; 95% confidence interval (CI), 1.192\u0026ndash;18.023; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027) In a retrospective study[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] of low anterior resection, 12% of stoma were not reversible, 11% required a repeat stoma after stoma closure and 10% received a late permanent stoma. The risk factor identified were male gender, low tumor site, advanced stage and anastomotic complications. Despite the reduction in recurrences over the past decade, the rate of permanent stoma did not change. One center from Seoul[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported anastomotic complication (7 out of 71 permanent stoma) to be the primary cause of early permanent stoma and recurrence (27 out of 71 permanent stoma) to be the cause of late permanent stoma. Yet another group[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] from Korea reported a series of 2528 patients who underwent surgery for low rectal cancers and had 28 out of 231 patients having permanent stoma due to either anastomotic leak or recurrence. Thus, metastatic status has been less recognised as a risk factor for stoma non-reversal. These studies have very small number of metastatic Ca rectum who underwent ISR, and thus cannot identify all the predictors of successful reversal. A higher number of cases of this subgroup is needed to conclusively prove the same.\u003c/p\u003e \u003cp\u003eIt may be inferred from these studies that doing ISR in metastatic Ca rectum is not without risks. Hence, patients must be chosen more carefully for ISR in metastatic setting. There isn\u0026rsquo;t compelling evidence to preclude ISR in metastatic cases. A clear lesson learnt from this analysis is that patients must be explained about the chances of non-reversal.\u003c/p\u003e \u003cp\u003eOur study is not without limitations. It is a single- center retrospective study. The surgical failure was assessed in terms of local recurrence, persistent stoma rates and margin positivity. However, functional outcomes in term of sphincter tone, incontinence rates and low anterior resection scores were not recorded. Furthermore, ours is a group of robotic and laparoscopic ISR, hence the effects are blended and the heterogeneity in terms of surgical failure caused by adopting either approach is not well demarcated. A short-term follow-up of the recently operated group is another limitation hence part of our data is in the preliminary phase. Follow-up is going on and is expected to give mature results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that the patients who undergo ISR with pre-operative oligo metastasis experience higher recurrence and low stoma reversal rates without affecting margin positivity. It is a prerequisite to carefully counsel the patient as regards the chances of a permanent stoma in such scenarios. The patients\u0026rsquo; expectations may not be met if the early disease recurrence hampers stoma reversal in oligometastatic cases. Hence, higher than usual chances of a stoma non-reversal must be acceded by the patient while consenting for this procedure. Since the number of patients with oligo-metastasis is very low in the present study, a larger sample size is required to translate this conjecture into evidence.\u003c/p\u003e"},{"header":"Statements and declarations","content":"\u003cp\u003eThe authors have no competing interests and funding to declare.\u003c/p\u003e\n\u003cp\u003eAuthor contributions:\u003c/p\u003e\n\u003cp\u003eAvanish Saklani contributed to study conception and design. Material preparation, data collection and analysis was performed by Abdeali Saif Arif Kaderi, Ankit Sharma and Sanjay Singh. The first draft of manuscript was written by Abdeali Saif Arif Kaderi. Mufaddal Kazi and Avanish Saklani commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCompliance and ethical standards:\u003c/p\u003e\n\u003cp\u003eNo conflicts of interest to disclose. This research was a retrospective study of already existing data of human participants Ethics committee was approached and waiver of consent was taken for this retrospective study. No funding was received for conducting this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eR. Schiessel, J. Karner-Hanusch, F. Herbst, B. Teleky, and M. Wunderlich, \u0026ldquo;Intersphincteric resection for low rectal tumours,\u0026rdquo; \u003cem\u003eBr J Surg\u003c/em\u003e, vol. 81, no. 9, pp. 1376\u0026ndash;1378, Sep. 1994, doi: 10.1002/bjs.1800810944.\u003c/li\u003e\n \u003cli\u003eR. Adam, A. Laurent, D. Azoulay, D. Castaing, and H. Bismuth, \u0026ldquo;Two-Stage Hepatectomy: A Planned Strategy to Treat Irresectable Liver Tumors:,\u0026rdquo; \u003cem\u003eAnnals of Surgery\u003c/em\u003e, vol. 232, no. 6, pp. 777\u0026ndash;785, Dec. 2000, doi: 10.1097/00000658-200012000-00006.\u003c/li\u003e\n \u003cli\u003eF. Calderon Novoa \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?,\u0026rdquo; \u003cem\u003eCancers\u003c/em\u003e, vol. 15, no. 7, p. 2113, Apr. 2023, doi: 10.3390/cancers15072113.\u003c/li\u003e\n \u003cli\u003eW. M. Lo, S. T. Tohme, and D. A. Geller, \u0026ldquo;Recent Advances in Minimally Invasive Liver Resection for Colorectal Cancer Liver Metastases\u0026mdash;A Review,\u0026rdquo; \u003cem\u003eCancers\u003c/em\u003e, vol. 15, no. 1, p. 142, Dec. 2022, doi: 10.3390/cancers15010142.\u003c/li\u003e\n \u003cli\u003eR. Hernandez-Alejandro, L. I. Ruffolo, R. Alikhanov, B. Bj\u0026ouml;rnsson, O. J. M. Torres, and A. Serrablo, \u0026ldquo;Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis,\u0026rdquo; \u003cem\u003eInternational Journal of Surgery\u003c/em\u003e, vol. 82, pp. 103\u0026ndash;108, Oct. 2020, doi: 10.1016/j.ijsu.2020.04.009.\u003c/li\u003e\n \u003cli\u003eE. Al-Sharif, \u0026ldquo;Portal vein embolization effect on colorectal cancer liver metastasis progression: Lessons learned,\u0026rdquo; \u003cem\u003eWJCO\u003c/em\u003e, vol. 6, no. 5, p. 142, 2015, doi: 10.5306/wjco.v6.i5.142.\u003c/li\u003e\n \u003cli\u003eR. Adam \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Patients With Initially Unresectable Colorectal Liver Metastases: Is There a Possibility of Cure?,\u0026rdquo; \u003cem\u003eJCO\u003c/em\u003e, vol. 27, no. 11, pp. 1829\u0026ndash;1835, Apr. 2009, doi: 10.1200/JCO.2008.19.9273.\u003c/li\u003e\n \u003cli\u003eJ. Gori \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Comparative study of functional outcomes between ultra‐low anterior resection and inter‐sphincteric resection: a propensity matched analysis,\u0026rdquo; \u003cem\u003eANZ Journal of Surgery\u003c/em\u003e, vol. 92, no. 1\u0026ndash;2, pp. 151\u0026ndash;156, Jan. 2022, doi: 10.1111/ans.17405.\u003c/li\u003e\n \u003cli\u003eC.-Y. Kuo \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for patients with rectal cancer having undergoing sphincter-saving operation,\u0026rdquo; \u003cem\u003eAsian Journal of Surgery\u003c/em\u003e, vol. 46, no. 5, pp. 1944\u0026ndash;1950, May 2023, doi: 10.1016/j.asjsur.2022.09.107.\u003c/li\u003e\n \u003cli\u003eS. P. Puntambekar \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers,\u0026rdquo; \u003cem\u003eLaparoscopic, Endoscopic and Robotic Surgery\u003c/em\u003e, vol. 6, no. 2, pp. 57\u0026ndash;62, Jun. 2023, doi: 10.1016/j.lers.2023.04.001.\u003c/li\u003e\n \u003cli\u003eK. Shirouzu, N. Murakami, and Y. Akagi, \u0026ldquo;Intersphincteric resection for very low rectal cancer: A review of the updated literature,\u0026rdquo; \u003cem\u003eAnnals of Gastroent Surgery\u003c/em\u003e, vol. 1, no. 1, pp. 24\u0026ndash;32, Apr. 2017, doi: 10.1002/ags3.12003.\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;2024 ASCRS Annual Scientific Meeting.\u0026rdquo; Accessed: Apr. 10, 2024. [Online]. Available: https://ascrs24.eventscribe.net/fsPopup.asp?PresentationID=1356883\u0026amp;mode=presInfo\u003c/li\u003e\n \u003cli\u003eA. L. Desouza, M. Kazi, K. Verma, P. Sugoor, B. K. Mahendra, and A. P. Saklani, \u0026ldquo;Local recurrence with intersphincteric resection in adverse histology rectal cancers. A retrospective study with competing risk analysis,\u0026rdquo; \u003cem\u003eANZ Journal of Surgery\u003c/em\u003e, vol. 91, no. 11, pp. 2475\u0026ndash;2481, 2021, doi: 10.1111/ans.17155.\u003c/li\u003e\n \u003cli\u003eM. Kazi \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Simultaneous resection of synchronous colorectal liver metastasis: Feasibility and development of a prediction model,\u0026rdquo; \u003cem\u003eAnn Hepatobiliary Pancreat Surg\u003c/em\u003e, vol. 27, no. 1, pp. 40\u0026ndash;48, Feb. 2023, doi: 10.14701/ahbps.22-043.\u003c/li\u003e\n \u003cli\u003eW. C. Zewude, T. Derese, Y. Suga, and B. Teklewold, \u0026ldquo;Quality of Life in Patients Living with Stoma,\u0026rdquo; \u003cem\u003eEthiop J Health Sci\u003c/em\u003e, vol. 31, no. 5, pp. 993\u0026ndash;1000, Sep. 2021, doi: 10.4314/ejhs.v31i5.11.\u003c/li\u003e\n \u003cli\u003eX. Zhou, B. Wang, F. Li, J. Wang, and W. Fu, \u0026ldquo;Risk Factors Associated With Nonclosure of Defunctioning Stomas After Sphincter-Preserving Low Anterior Resection of Rectal Cancer: A Meta-Analysis,\u0026rdquo; \u003cem\u003eDiseases of the Colon \u0026amp; Rectum\u003c/em\u003e, vol. 60, no. 5, pp. 544\u0026ndash;554, May 2017, doi: 10.1097/DCR.0000000000000819.\u003c/li\u003e\n \u003cli\u003eG. G. David, J. P. Slavin, S. Willmott, D. J. Corless, A. U. Khan, and C. R. Selvasekar, \u0026ldquo;Loop ileostomy following anterior resection: is it really temporary?,\u0026rdquo; \u003cem\u003eColorectal Disease\u003c/em\u003e, vol. 12, no. 5, pp. 428\u0026ndash;432, May 2010, doi: 10.1111/j.1463-1318.2009.01815.x.\u003c/li\u003e\n \u003cli\u003eO. Song, K. H. Kim, S. Y. Lee, C. H. Kim, Y. J. Kim, and H. R. Kim, \u0026ldquo;Risk factors of stoma re-creation after closure of diverting ileostomy in patients with rectal cancer who underwent low anterior resection or intersphincteric resection with loop ileostomy,\u0026rdquo; \u003cem\u003eAnn Surg Treat Res\u003c/em\u003e, vol. 94, no. 4, p. 203, 2018, doi: 10.4174/astr.2018.94.4.203.\u003c/li\u003e\n \u003cli\u003eM. F. Sier, L. van Gelder, D. T. Ubbink, W. A. Bemelman, and R. J. Oostenbroek, \u0026ldquo;Factors affecting timing of closure and non-reversal of temporary ileostomies,\u0026rdquo; \u003cem\u003eInt J Colorectal Dis\u003c/em\u003e, vol. 30, no. 9, pp. 1185\u0026ndash;1192, Sep. 2015, doi: 10.1007/s00384-015-2253-3.\u003c/li\u003e\n \u003cli\u003eS. W. Lim, H. J. Kim, C. H. Kim, J. W. Huh, Y. J. Kim, and H. R. Kim, \u0026ldquo;Risk factors for permanent stoma after low anterior resection for rectal cancer,\u0026rdquo; \u003cem\u003eLangenbecks Arch Surg\u003c/em\u003e, vol. 398, no. 2, pp. 259\u0026ndash;264, Feb. 2013, doi: 10.1007/s00423-012-1038-1.\u003c/li\u003e\n \u003cli\u003eT. Junginger, U. G\u0026ouml;nner, T. T. Trinh, A. Lollert, K. Oberholzer, and M. Berres, \u0026ldquo;Permanent Stoma After Low Anterior Resection for Rectal Cancer,\u0026rdquo; \u003cem\u003eDiseases of the Colon \u0026amp; Rectum\u003c/em\u003e, vol. 53, no. 12, pp. 1632\u0026ndash;1639, Dec. 2010, doi: 10.1007/DCR.0b013e3181ed0aae.\u003c/li\u003e\n \u003cli\u003eS. I. Seo \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Characteristics and risk factors associated with permanent stomas after sphincter-saving resection for rectal cancer,\u0026rdquo; \u003cem\u003eWorld J Surg\u003c/em\u003e, vol. 37, no. 10, pp. 2490\u0026ndash;2496, Oct. 2013, doi: 10.1007/s00268-013-2145-z.\u003c/li\u003e\n \u003cli\u003eC. M. Lee \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Risk Factors of Permanent Stomas in Patients with Rectal Cancer after Low Anterior Resection with Temporary Stomas,\u0026rdquo; \u003cem\u003eYonsei Med J\u003c/em\u003e, vol. 56, no. 2, p. 447, 2015, doi: 10.3349/ymj.2015.56.2.447.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intersphincteric resection, Oligometastatic ISR, Stoma non-reversal, permanent stoma.","lastPublishedDoi":"10.21203/rs.3.rs-4369611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4369611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInter-sphincteric resection (ISR) is being increasingly performed in metastatic rectal adenocarcinoma (with oligo-metastasis) patients. There has been a trend towards worse prognosis in this group. This study compares the oncological and surgical outcomes of patients with and without pre-operative oligo-metastasis who underwent ISR. The outcomes compared include prognostic factors like margin positivity, recurrence rates, stoma reversal rate, surgical failure rate (defined as a combination of one or more of the aforestated factors). The demographic pattern, American Society of anaesthesia grade (ASA), treatment received, clinical and histopathological T and N stage, grade, type of MIS approach, neoadjuvant therapy and pathological high-risk features are also studied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who underwent minimally invasive ISR over ten years at a high-volume tertiary cancer centre were selected for the study. Factors used for the assessment of oncological outcomes were margin positivity (circumferential resection and distal margin), recurrence (both local and systemic) and stoma reversal rate. A descriptive and comparative analysis were performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour hundred and eight patients underwent minimally invasive ISR of which 25 (6.12%) patients were oligo-metastatic. Higher recurrence (24% versus 18.5%) and low stoma reversal rate (36.8% versus 67.3%) were observed in the oligo-metastatic group with statistically significant differences. Though no local recurrence was seen in the oligometastatic group the difference was not statistically different. Margin positivity was the same in both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study shows that oligometastatic patients who underwent ISR experienced higher recurrence and low stoma reversal rates without affecting margin positivity.\u003c/p\u003e","manuscriptTitle":"Is It Worth Performing Inter-Sphincteric Resection in Patients Having Rectal Adenocarcinoma with Oligo-Metastasis: A Study Of 416 Patients.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-31 04:52:02","doi":"10.21203/rs.3.rs-4369611/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a43ddb43-9c0b-4f9b-bcee-dbd5f4ee2986","owner":[],"postedDate":"May 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-19T07:42:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-31 04:52:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4369611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4369611","identity":"rs-4369611","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}