Recurrence of abdominal wall near incision of intestinal cancer

When colorectal cancer recurs in the abdominal wall near the incision, the first problem is to determine how to deal with the patient next. The ideal method is to remove the recurrence through another surgery and achieve a radical cure again. If there is distant metastasis, it will be more difficult to achieve a radical cure. Therefore, here we focus on the indications for reoperation for local recurrence after rectal cancer surgery. Clinically, we generally divide recurrence into the following three situations.

1. Local and distant recurrence

It is generally believed that distant metastasis is a contraindication to re-surgery. However, this is not absolute. In some cases, neoadjuvant therapy can be used to make unresectable distant metastases resectable, and the opportunity for re-surgery can also be obtained. For patients with multiple local recurrences, resection of multiple local lesions can be performed in some diagnosis and treatment centers. However, due to its high surgical mortality rate, it is not advisable to force it in hospitals without surgical experience, and it can be regarded as a contraindication to surgery.

2. Unresectable local recurrence

For patients with symptomatic local multiple recurrences, it is generally believed that radical resection is no longer possible. Palliative surgery cannot improve survival, but it is inappropriate to evaluate the efficacy of surgical resection only from the perspective of reducing mortality. Some palliative resections can improve the patient's quality of life and relieve their pain symptoms. Surgical treatment for symptom relief only requires the removal of large pieces of recurrent tumor tissue. Radiotherapy combined with chemotherapy is usually a common method after palliative surgery because it can relieve pain, reduce bleeding, and improve quality of life. Selective chemotherapy of pelvic blood vessels has a tumor-reducing effect on unresectable tumors. If the recurrent lesion is close to the anus, an endoluminal stent or colostomy is required. For patients with bleeding symptoms, other optional treatments include laser ablation, electrocautery, and vascular embolization. For local resection of perineal recurrence, abdominoperineal combined proctocolectomy can be selected, but it can lead to pelvic spread and poor prognosis.

3. Resectable local recurrence

For resectable local recurrences without distant metastasis, surgical resection is the only treatment option. The surgical approach for pelvic recurrence after rectal cancer surgery is determined by the site and extent of the recurrence. The goal of resection is to have no cancer cells at the microscopic incision margin, that is, R0 resection. If cancer cells are visible at the incision margin under the microscope, it is an R1 resection. If cancer cells are visible at the incision margin under the naked eye, it is an R2 resection. The survival rates of R1 and R2 resections are much worse than those of R0, and they are considered palliative surgeries. In order to achieve R0 resection, it may be necessary to remove adjacent pelvic organs and the sacrum, but some patients may not be able to undergo R0 resection.

Advanced patients include patients with tumor infiltration of the pelvic sidewall, lower extremity edema due to involvement of the iliac vessels, bilateral hydronephrosis due to bilateral ureteral obstruction, lower extremity muscle weakness due to invasion of the sciatic nerve, tumor invasion of the sciatic notch, and lymph node metastasis around the abdominal aorta, etc. Limited invasion of the pelvic sidewall and invasion of the sacrum above S2 are considered relative contraindications because the possibility of adequate resection is small.