Research on relation between preoperative staging and surgical decision-making in patients with rectal cancer: a real-world study based on DACCA database_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

HE Qianqiaozhi ^1,2 , JI Lisi ^1,2 , MEI Lüou ^1,2 ,  WANG Xiaodong ¹ , LI Li ^3,4 , WEI Mingtian ⁴

1. Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. West China School of Medicine in Sichuan University, Chengdu 610041, P. R. China;
3. Department of General Surgery II, West China Hospital of Shangjin, Sichuan University, Chengdu 611731, P. R. China;
4. Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

WANG Xiaodong, Email: wangxiaodong@wchscu.cn

Keywords：

rectal cancer; preoperative staging; surgical approach; sphincter-preserving surgery; intersphincteric resection; Database from Colorectal Cancer

DOI：

10.7507/1007-9424.202503034

Video：

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Objective To analyze the relation between preoperative staging and surgical decision-making in rectal cancer patients from the West China Colorectal Cancer Database (DACCA) and to identify key factors influencing the selection of surgical approaches. Methods Based on the updated DACCA dataset as of April 24, 2024, the patients with rectal cancer were included. Chi-square tests and logistic regression analyses were performed to evaluate the correlation between preoperative staging [(y)cTNM stage] and the selection of sphincter-preserving surgery or intersphincteric resection (ISR). Additional factors, including age, body mass index (BMI), tumor location, and nutritional score, were assessed for their impact on surgical choices. Results A total of 2 733 rectal cancer patients were included. Preoperative (y)cTNM staging distribution was as follows: Stage 0 (0.8%, n=23), stageⅠ (14.2%, n=388), stage Ⅱ (27.8%, n=760), stage Ⅲ (31.9%, n=873), and stage Ⅳ (25.2%, n=689). Advanced preoperative staging (Stages II–IV) was independently associated with non–sphincter-preserving surgery (Stage II: OR=0.073; Stage III: OR=0.068; Stage IV: OR=0.039; all P<0.001). Low/ultralow rectal tumors were a risk factor for sphincter preservation failure (OR=0.491, 95% CI: 0.358–0.672) but significantly increased ISR utilization (OR=76.658, P<0.001). Nutritional scores of 4 (OR=0.261) and 6 (OR=0.098) correlated with reduced ISR implementation (both P<0.05). Conclusions Preoperative staging serves as the cornerstone for surgical decision-making in rectal cancer, with advanced stages favoring non–sphincter-preserving and non-ISR approaches. While low/ultralow tumors challenge sphincter preservation, ISR remains a predominant option. Tumor anatomy and nutritional status critically influence surgical strategy, necessitating comprehensive preoperative evaluation.

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2.	中国抗癌协会结直肠癌专业委员会. 中国结直肠癌诊疗规范(2025年版). 中华肿瘤杂志, 2025, 47(3): 201-215.
3.	汪晓东, 刘健博, 李立. 数据库建设第五部分·结直肠癌的肿瘤特征—模块的设计(二). 中国普外基础与临床杂志, 2020, 27(4): 483-488.
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6.	朱利微, 徐淑云, 辛海龙, 等. NRS2002营养风险筛查的临床应用及研究. 当代医学, 2011, 17(8): 30.
7.	汪晓东, 刘健博, 李立. 数据库建设第三部分: 结直肠癌内外科合并症及术前体质状态的标签与结构化. 中国普外基础与临床杂志, 2019, 26(9): 1110-1115.
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9.	国家癌症中心中国结直肠癌筛查与早诊早治指南制定专家组. 中国结直肠癌筛查与早诊早治指南(2020, 北京). 中国肿瘤, 2021, 30(1): 1-28.
10.	汪晓东, 林容若, 刘健博, 等. 数据库建设第七部分: 结直肠癌手术特征的标签与结构化(一). 中国普外基础与临床杂志, 2020, 27(9): 1150-1152.
11.	Benson AB, Venook AP, Al-Hawary MM, et al. NCCN guidelines insights: Rectal cancer, version 6. 2020. J Natl Compr Canc Netw, 2020, 18(7): 806-815.
12.	Glynne-Jones R, Wyrwicz L, Tiret E, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2017, 28(suppl_4): iv22-iv40. doi: 10.1093/annonc/mdx224.
13.	Nagtegaal ID, Tot T, Jayne DG, et al. Lymph nodes, tumor deposits, and TNM: are we getting better?. J Clin Oncol, 2011, 29(18): 2487-2492.
14.	Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med, 2004, 351(17): 1731-1740.
15.	van der Valk MJM, Hilling DE, Bastiaannet E, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet, 2018, 391(10139): 2537-2545.
16.	Quirke P, Steele R, Monson J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet, 2009, 373(9666): 821-828.
17.	Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—The clue to pelvic recurrence?. Br J Surg, 1982, 69(10): 613-616.
18.	Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med, 2001, 345(9): 638-646.
19.	Weimann A, Braga M, Carli F, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr, 2017, 36(3): 623-650.
20.	Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr, 2017, 36(1): 11-48.
21.	Garcia-Aguilar J. Chemoradiotherapy and local excision for organ preservation in early rectal cancer—The end of the beginning?. JAMA Surg, 2019, 154(1): 54-55.

1. 王颢, 傅传刚. 直肠癌术前准确分期价值及对治疗策略选择的影响. 中国实用外科杂志, 2014, 34(1): 37-40.
2. 中国抗癌协会结直肠癌专业委员会. 中国结直肠癌诊疗规范(2025年版). 中华肿瘤杂志, 2025, 47(3): 201-215.
3. 汪晓东, 刘健博, 李立. 数据库建设第五部分·结直肠癌的肿瘤特征—模块的设计(二). 中国普外基础与临床杂志, 2020, 27(4): 483-488.
4. 汪晓东, 刘健博, 李立. 数据库建设第五部分: 结直肠癌的肿瘤特征—模块的设计(一). 中国普外基础与临床杂志, 2020, 27(3): 345-349.
5. 汪晓东, 李立. 数据库建设第一部分: 个人数据的标签与结构化. 中国普外基础与临床杂志, 2019, 26(3): 335-342.
6. 朱利微, 徐淑云, 辛海龙, 等. NRS2002营养风险筛查的临床应用及研究. 当代医学, 2011, 17(8): 30.
7. 汪晓东, 刘健博, 李立. 数据库建设第三部分: 结直肠癌内外科合并症及术前体质状态的标签与结构化. 中国普外基础与临床杂志, 2019, 26(9): 1110-1115.
8. 中华人民共和国国家卫生健康委员会. 中国结直肠癌诊疗规范(2020年版). 中华外科杂志, 2020, 58(8): 561-585.
9. 国家癌症中心中国结直肠癌筛查与早诊早治指南制定专家组. 中国结直肠癌筛查与早诊早治指南(2020, 北京). 中国肿瘤, 2021, 30(1): 1-28.
10. 汪晓东, 林容若, 刘健博, 等. 数据库建设第七部分: 结直肠癌手术特征的标签与结构化(一). 中国普外基础与临床杂志, 2020, 27(9): 1150-1152.
11. Benson AB, Venook AP, Al-Hawary MM, et al. NCCN guidelines insights: Rectal cancer, version 6. 2020. J Natl Compr Canc Netw, 2020, 18(7): 806-815.
12. Glynne-Jones R, Wyrwicz L, Tiret E, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2017, 28(suppl_4): iv22-iv40. doi: 10.1093/annonc/mdx224.
13. Nagtegaal ID, Tot T, Jayne DG, et al. Lymph nodes, tumor deposits, and TNM: are we getting better?. J Clin Oncol, 2011, 29(18): 2487-2492.
14. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med, 2004, 351(17): 1731-1740.
15. van der Valk MJM, Hilling DE, Bastiaannet E, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet, 2018, 391(10139): 2537-2545.
16. Quirke P, Steele R, Monson J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet, 2009, 373(9666): 821-828.
17. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—The clue to pelvic recurrence?. Br J Surg, 1982, 69(10): 613-616.
18. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med, 2001, 345(9): 638-646.
19. Weimann A, Braga M, Carli F, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr, 2017, 36(3): 623-650.
20. Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr, 2017, 36(1): 11-48.
21. Garcia-Aguilar J. Chemoradiotherapy and local excision for organ preservation in early rectal cancer—The end of the beginning?. JAMA Surg, 2019, 154(1): 54-55.

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