P-0294 Concurrent Neo-Adjuvant Chemo-Radiotherapy Using Capecitabine and Sphincter Sparing by Trans-Anal Abdominally Assisted Colonic Pull-Though in Locally Advanced Rectal Cancer

ABSTRACT Introduction Fluorouracil-based preoperative chemo-radiation is the current standard of care for locally advanced rectal cancer. The significance of using Capecitabine as a neo-adjuvant arises from its pharmacokinetic characteristics; it is a pro-drug with a complex enzymatic activation pathway and which in its final part generates 5-FU within the tumor cells itself, thus has the advantage of reducing systemic toxicity. Many variations of the pull-through concept have been introduced and modified by different workers during the last decades and its main principle is to have an anastomotic line totally diverted from fecal contamination. This study was designed to determine clinical response rate in locally advanced rectal cancer patients treated with preoperative regimen followed by surgical resection. Also it studies the validity of the technique of abdominally assisted trans-anal pull through as a sphincter preserving procedure in such patients. Methods Clinical and pathological data from 2008 to 2011 of a prospectively maintained thirty three patients of locally advanced rectal cancer database were examined. These patients received preoperative concurrent chemo-radiotherapy by using Oral fluoropyrimidines (Capecitabine). After re-staging, all patients were subjected to surgery in the form of abdominally assisted trans-anal colo-anal pull through as a sphincter preserving procedure or to abdomino-perineal resection. The former technique includes two parts abdominal part and anal one. A circumferential full thickness resection of the rectal wall above the ano-rectal junction was done. In ultra-low rectal cancer, the anal mucosa above the dentate line and the internal sphincter were either partially or totally resected as well. After procto-sigmoidectomy, a healthy part of colon was pulled out through the anus (Designed Colo-Anal Intussusceptions) and fixed in place by 4 to 6 stay sutures. A length of 8 to 10 cm of pulled stump was left outside the anal verge. In all patients we didn't do any diverting stoma. Results Thirty-three patients were identified (54.5%) male and (45.5%) females with median age of 40 yrs. old (range 17–80 y). As regard tumor response to neo-adjuvant therapy; 18/33 patients (54.5%) achieved complete response, 8/33 patients (24%) achieved partial response and 7/33 patients (21%) had no response. Trans-anal abdominally assisted colo-anal pull-through was performed in 27 patients (81.8%) and 6 patients (18 %) underwent abdomino-perineal resection. The main post-operative complications were fistula in 2 cases (6%) and partial stump ischemia in 3 (9%). We had a median disease free survival of 9.5 months and reported a 93% local control rate and 6.6% local failure rate after a maximum follow up period of 15 months. Conclusion Preoperative chemo-radiotherapy by using Capecitabine improves down staging in locally advanced rectal cancers. It is safe, effective, convenient and well tolerated by the patients. The study assumes that the surgical technique of Trans-Anal Abdominally Assisted Colo-Anal Pull Through for rectal cancer has many advantages as a sphincter-preserving technique; it is efficient and safe procedure providing acceptable oncological and functional results while minimizing local infection and avoiding the diverting stoma with its negative impact on the quality of life.