The Shifting and Evolving Neoadjuvant Treatments and Surgical Platforms on Oncological Outcomes and Sphincter Preservation in Distal Rectal Cancer: A 23-Year Retrospective Experience

This study aims to evaluate how advancements in surgical technology and evolving neoadjuvant treatment (NAT) protocols have influenced clinical, pathological, and long-term oncological outcomes in patients with locally advanced distal rectal cancer (LADRC). Particular emphasis is placed on how the evolving practice of a single high-volume colorectal surgeon has mirrored these developments over a 23-year period.

This retrospective cohort included 561 patients with LADRC who underwent NAT between 2001 and 2024. Patients were stratified into two groups based on the year 2013, which marked the institutional adoption of robotic surgery, high-resolution 3-Tesla MRI, and the formal implementation of the Watch-and-Wait (W&W) strategy: Group I (2001-2012) and Group II (2013-2024).

The median follow-up duration was significantly longer in Group 1 (191 ± 2.29 months) compared to Group 2 (71 ± 2.81 months). Local recurrence (LR) occurred in 11.6% of patients in Group 1 and 6.9% in Group 2 (p = 0.107), while distant metastasis (DM) was observed in 15.5% and 10.6%, respectively (p = 0.178) (Fig. 2). Disease-free survival (DFS) at 5 years was 67.4% (95% CI: 58.6-74.8) in Group 1 and 80.1% (95% CI: 75.6-83.8) in Group 2 (p = 0.003). At 10 years, DFS was 65.2% (95% CI: 58.6-74.8) and 79.4% (95% CI: 74.7-83.3) in Groups 1 and 2, respectively (p = 0.006). Similarly, overall survival (OS) at 5 years was 78.0% (95% CI: 67.6-82.4) in Group 1 and 91.7% (95% CI: 87.9-93.3) in Group 2 (p < 0.001). At 10 years, OS was 73.4% (95% CI: 66.0-81.1) and 90.5% (95% CI: 87.3-92.9), respectively (p < 0.001). Additionally, permanent stoma-free survival (PSFS) improved significantly over time, from 56.5% in Group 1 to 85.8% in Group 2 (p < 0.001).

The integration of robotic surgery, high-resolution MRI, and the W&W strategy has significantly improved oncological outcomes and sphincter preservation rates in patients with LADRC over the past two decades.