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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El c&#225;ncer colorrectal &#40;CCR&#41; es la enfermedad maligna del tracto digestivo m&#225;s com&#250;n y su incidencia se ha incrementado en a&#241;os recientes&#44; en particular en &#225;reas que se consideran de bajo riesgo&#44; como los pa&#237;ses en v&#237;as de desarrollo<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a>&#46; En 2016&#44; se reportaron aproximadamente 34&#44;280 casos nuevos de CCR&#44; con 16&#44;660 de estos en hombres y 17&#44;620 mujeres<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a>&#46; El c&#225;ncer de recto es aproximadamente el 30&#37; de los pacientes con CCR<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La evidencia presentada en estudios anteriores muestra que hasta el 70&#37; de los pacientes con c&#225;ncer de recto no metast&#225;sico est&#225;n en etapa T3 o con afectaci&#243;n ganglionar<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a>&#46; El manejo actual del c&#225;ncer de recto en etapa avanzada se ha orientado hacia un abordaje de caso por caso basado en la estadificaci&#243;n preoperatoria&#44; quimiorradioterapia y la subsiguiente estadificaci&#243;n&#46; La radioquimioterapia neoadyuvante &#40;RQTN&#41; he mejorado el control local y los resultados a largo plazo&#44; adem&#225;s de facilitar los procedimientos de preservaci&#243;n de esf&#237;nter<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4-6</span></a>&#46; Sin embargo&#44; los procedimientos de preservaci&#243;n de esf&#237;nter con extirpaci&#243;n mesorrectal total &#40;EMT&#41; son imposibles de realizar en ocasiones&#44; incluso tras RQTN prolongada<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a>&#46; La elecci&#243;n de resecci&#243;n anterior baja &#40;RAB&#41; con anastomosis colorrectal con grapas&#44; anastomosis coloanal ultra baja&#44; o resecci&#243;n abdominoperineal &#40;RAP&#41; depende de la altura del tumor&#44; el grado de invasi&#243;n local y la habilidad del cirujano&#46; Aunque dichos procedimientos quir&#250;rgicos no son directamente comparables&#44; algunos estudios han demostrado que los pacientes que son tratados con RAP tienen una peor prognosis que los que son tratados con RAB<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; Sin embargo&#44; en otros estudios no se han descrito diferencias en las tasas de recurrencia local en la comparaci&#243;n de los dos procedimientos<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7&#44;10</span></a>&#46; Por otro lado&#44; existen dudas respecto a una mayor tasa de recurrencia local debido a la extirpaci&#243;n incompleta de la enfermedad a nivel microsc&#243;pico en los m&#225;rgenes radial y distal en pacientes tratados con RAB&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hasta la fecha no existe evidencia de que la RAP en s&#237; misma tenga peores desenlaces que la RAB&#46; Por lo tanto&#44; el prop&#243;sito del presente estudio fue comparar los desenlaces oncol&#243;gicos de RAB y RAP en el tratamiento de pacientes con c&#225;ncer de recto distal en un periodo de 10<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46; Tambi&#233;n se analizaron los factores de riesgo de recurrencia y sobrevida general&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Se obtuvieron datos de pacientes consecutivos con c&#225;ncer de recto distal de una base de datos prospectiva&#46; Dichos pacientes se sometieron a tratamiento curativo quir&#250;rgico en el Servicio de Cirug&#237;a de Colon y Recto del Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo entre 2002 y 2012 y los datos fueron analizados retrospectivamente&#46; Dada la naturaleza retrospectiva del presente estudio&#44; no se requiri&#243; de la autorizaci&#243;n de los pacientes para la obtenci&#243;n de los datos&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Los procedimientos con preservaci&#243;n de esf&#237;nter&#44; como la resecci&#243;n baja o ultrabaja con anastomosis colorrectal o coloanal &#40;RAB&#41;&#44; fueron comparados con la RAP en pacientes con c&#225;ncer de recto distal avanzado localizado dentro de un rango de 5<span class="elsevierStyleHsp" style=""></span>cm del canal anal inferior&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los siguientes factores fueron estudiados y analizados&#58; sexo&#44; edad&#44; tratamiento neoadyuvante&#44; etapa<span class="elsevierStyleHsp" style=""></span>T&#44; afectaci&#243;n ganglionar&#44; n&#250;mero de ganglios obtenidos en el esp&#233;cimen&#44; tipo histol&#243;gico y diferenciaci&#243;n de tumor&#46; Estos factores fueron evaluados en relaci&#243;n a la prognosis&#44; como recurrencia local&#44; sobrevida general y sobrevida libre de enfermedad&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se excluy&#243; a pacientes con carcinomatosis peritoneal o met&#225;stasis distante avanzada &#40;enfermedad en etapa<span class="elsevierStyleHsp" style=""></span>IV&#41;&#44; c&#225;ncer colorrectal u otros c&#225;nceres no colorrectales s&#237;ncronos&#44; m&#225;rgenes involucrados&#44; c&#225;ncer de recto en el contexto de enfermedad intestinal inflamatoria&#44; poliposis adenomatosa familiar o radioterapia p&#233;lvica previa&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los pacientes con c&#225;ncer de recto en etapa avanzada se sometieron a RQTN&#46; Los pacientes fueron evaluados por etapa de enfermedad antes y despu&#233;s del tratamiento neoadyuvante por el mismo equipo de cirujano colorrectal y onc&#243;logo por medio de examen rectal digital&#44; proctoscopia&#44; colonoscopia&#44; RM y TC de pecho y abdomen&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El tratamiento neoadyuvante consisti&#243; en un bolo de 350<span class="elsevierStyleHsp" style=""></span>mg&#47;<span class="elsevierStyleSup">2</span>&#44; 5-Fluoracil los primeros y &#250;ltimos 5<span class="elsevierStyleHsp" style=""></span>d&#237;as del tratamiento&#44; en concomitancia con radioterapia&#46; La dosis total de radiaci&#243;n p&#233;lvica fue de 5&#44;040<span class="elsevierStyleHsp" style=""></span>Gy&#44; la cual fue proporcionada en 28 sesiones consecutivas de 180<span class="elsevierStyleHsp" style=""></span>Gy&#46; La re-estadificaci&#243;n se realiz&#243; entre las 8 y las 12<span class="elsevierStyleHsp" style=""></span>semanas y el tratamiento quir&#250;rgico fue realizado aproximadamente a las 12-14<span class="elsevierStyleHsp" style=""></span>semanas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Todos los espec&#237;menes quir&#250;rgicos fueron examinados histol&#243;gicamente y fueron clasificados de acuerdo a la estadificaci&#243;n UICC TNM&#46; Se utiliz&#243; tinci&#243;n con hematoxilina-eosina para identificar los ganglios &#40;G&#41;&#46; No se realiz&#243; evaluaci&#243;n inmunohistoqu&#237;mica ni <span class="elsevierStyleItalic">bread loafing</span> de manera rutinaria&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Tratamiento quir&#250;rgico</span><p id="par0055" class="elsevierStylePara elsevierViewall">El tratamiento quir&#250;rgico incluy&#243; rectosigmoidectom&#237;a con EMT y ligamiento de la arteria mesent&#233;rica inferior en la ra&#237;z&#46; Las opciones quir&#250;rgicas eran la resecci&#243;n anterior baja o ultra baja con preservaci&#243;n del esf&#237;nter o RAP&#46; La decisi&#243;n de realizar la cirug&#237;a con preservaci&#243;n de esf&#237;nter estuvo basada en la evaluaci&#243;n de la afectaci&#243;n del esf&#237;nter durante las pruebas de re-estadificaci&#243;n y el examen proctol&#243;gico para obtener m&#225;rgenes oncol&#243;gicos circunferenciales y distales libres de tumor&#46; Todos los procedimientos quir&#250;rgicos fueron realizados por cirujanos de c&#225;ncer colorrectal certificados que se apegaron a los principios de la resecci&#243;n oncol&#243;gica radical&#46; La disecci&#243;n del mesocolon y la EMT con resecci&#243;n en bloque de &#243;rganos contiguos fue realizada cuando se detect&#243; adhesi&#243;n o invasi&#243;n macrosc&#243;pica tumoral&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">An&#225;lisis estad&#237;stico</span><p id="par0060" class="elsevierStylePara elsevierViewall">El presente estudio fue aprobado por el <span class="elsevierStyleItalic">Institutional Review Board</span> &#40;IRB&#41; en la Escuela de Medicina de la Universidad de Sao Paulo &#40;FMUSP&#41;&#44; en Sao Paulo&#44; Brasil&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas del tumor y de los pacientes fueron descritas y comparadas entre dos grupos&#44; haciendo uso de frecuencias relativas y absolutas y la prueba de chi cuadrado&#44; la prueba exacta de Fisher o la prueba de raz&#243;n de verosimilitud&#46; Las dos &#250;ltimas pruebas fueron utilizadas cuando la muestra no era adecuada para la evaluaci&#243;n por medio de la prueba de chi cuadrado&#46; Para el an&#225;lisis multivariado se utiliz&#243; un modelo de regresi&#243;n log&#237;stica que incluy&#243; variables con nivel de significancia debajo de 0&#46;2 en el an&#225;lisis bivariado&#46; Los datos fueron analizados utilizando el software Windows SPSS 20&#46;0&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Para evaluar la sobrevida general con base en cada variable analizada se estim&#243; el tiempo medio de sobrevida utilizando el m&#233;todo Kaplan-Meier&#46; La raz&#243;n de riesgo &#40;RR&#41; fue estimada con un intervalo de confianza de 95&#37; utilizando regresi&#243;n de Cox bivariada de riesgos proporcionales&#46; La regresi&#243;n de Cox multivariada fue aplicada para las variables que influenciaban la sobrevida general&#46; Los modelos finales incluyeron variables con niveles de significancia debajo de 0&#46;05&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Consideraciones &#233;ticas</span><p id="par0075" class="elsevierStylePara elsevierViewall">El presente estudio fue aprobado por el IRB de nuestro hospital y el Comit&#233; de &#201;tica&#46; Se obtuvo el consentimiento informado de todos los participantes incluidos en el estudio antes de su participaci&#243;n&#46; Los pacientes siempre fueron tratados de acuerdo a los protocolos internacionales est&#225;ndar&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0080" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el IRB del hospital&#46; El diagrama de flujo en la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> resume los procesos de inclusi&#243;n y exclusi&#243;n y la selecci&#243;n de pacientes con c&#225;ncer de recto distal que se sometieron a RAB o RAB&#44; para ser comparados&#46; Entre los 928 pacientes que se sometieron a cirug&#237;a por c&#225;ncer colorrectal&#44; 171 &#40;18&#37;&#41; ten&#237;an c&#225;ncer en la parte baja del recto&#46; Se excluy&#243; a 23 pacientes&#44; con lo que el total fue de 148&#46; Setenta y ocho de los pacientes fueron mujeres &#40;52&#46;7&#37;&#41; y la media de edad de los pacientes fue de 61&#46;2<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46; Respecto a los procedimientos quir&#250;rgicos&#44; 62 &#40;41&#46;9&#37;&#41; de los pacientes se sometieron a RAB y 86 &#40;58&#46;1&#37;&#41; se sometieron a RAP&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se resumen y se comparan los par&#225;metros entre los grupos RAB y RAP y el n&#250;mero total de los pacientes estudiados&#46; Ciento veintiocho &#40;86&#46;5&#37;&#41; de los pacientes fueron tratados con RQTN antes de la cirug&#237;a y 20 pacientes &#40;13&#46;5&#37;&#41; fueron candidatos para tratamiento quir&#250;rgico de manera directa&#46; La mayor&#237;a de los pacientes ten&#237;an c&#225;ncer de recto local avanzado&#44; con el 62&#46;1&#37; de ellos en etapas T3 y T4&#46; Adem&#225;s&#44; 41 pacientes &#40;27&#46;7&#37;&#41; ten&#237;an afectaci&#243;n ganglionar&#46; La comparaci&#243;n entre los grupos revel&#243; que no exist&#237;an diferencias significativas en las variables analizadas &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Se utiliz&#243; laparoscopia en el 58&#37; de nuestros procedimientos&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">La mortalidad general a los 30<span class="elsevierStyleHsp" style=""></span>d&#237;as fue del 2&#46;7&#37;&#44; con 3<span class="elsevierStyleHsp" style=""></span>muertes &#40;3&#46;4&#37;&#41; en el grupo RAP y 1 &#40;1&#46;6&#37;&#41; en el grupo RAB&#46; No existieron diferencias significativas entre los grupos&#46; Todos los par&#225;metros analizados entre los grupos RAB y RAP no estuvieron asociados significativamente con mortalidad de 30<span class="elsevierStyleHsp" style=""></span>d&#237;as&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se compara la recurrencia en todos los par&#225;metros analizados&#44; incluido el tipo de cirug&#237;a&#46; En el an&#225;lisis univariado&#44; los pacientes mayores de 40<span class="elsevierStyleHsp" style=""></span>a&#241;os &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;039&#41;&#44; el uso de radio quimioterapia neoadyuvante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;045&#41;&#44; los tumores con diferenciaci&#243;n pobre &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;026&#41; y los pacientes que se sometieron a RAP &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41; presentaron un riesgo de recurrencia significativamente m&#225;s alto&#46; El an&#225;lisis multivariado revel&#243; que los pacientes con tumores con diferenciaci&#243;n pobre presentaron 7&#46;51 veces m&#225;s probabilidad de recurrencia local que los pacientes con buena o moderada diferenciaci&#243;n de tumor &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;028&#41;&#46; Adem&#225;s&#44; los pacientes que se sometieron a RAP presentaron una probabilidad 2&#46;95 veces mayor de recurrencia local que los pacientes que se sometieron a RAB &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">La sobrevida general de 5<span class="elsevierStyleHsp" style=""></span>a&#241;os fue del 58&#46;1&#37;&#46; Cuando se realiz&#243; la estadificaci&#243;n por tipo de cirug&#237;a&#44; la tasa de sobrevida fue m&#225;s baja en el grupo RAP &#40;46&#46;5&#37;&#41; que en el grupo RAB &#40;74&#46;2&#37;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La media para el tiempo de seguimiento fue de 32<span class="elsevierStyleHsp" style=""></span>meses &#40;de 16 a 59&#46;5<span class="elsevierStyleHsp" style=""></span>meses&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se muestra que la etapa T avanzada&#44; la etapa N-positiva&#44; el tipo histol&#243;gico mucinoso y la cirug&#237;a RAP estuvieron correlacionados con un mayor riesgo de mortalidad &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; El modelo de regresi&#243;n log&#237;stica revel&#243; que los pacientes con enfermedad T3 tuvieron 4&#46;63 veces mayor riesgo de muerte &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;011&#41; y los pacientes con enfermedad T4 tuvieron 6&#46;12 veces mayor riesgo de muerte &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41; que los pacientes con enfermedad T1&#47;T2&#46; Adem&#225;s&#44; los pacientes que se sometieron a RAP presentaron un riesgo de muerte 2&#46;14<span class="elsevierStyleHsp" style=""></span>veces mayor que los pacientes que se sometieron a RAB &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> se muestra que los pacientes que se sometieron a RAB con EMT presentaron tasas de sobrevida general mayores que los pacientes que se sometieron a RAP&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se muestra que los pacientes con etapa T avanzada&#44; afectaci&#243;n ganglionar y diferenciaci&#243;n de tumor pobre&#44; al igual que aquellos que se sometieron a cirug&#237;a RAP&#44; presentaron tasas de sobrevida libre de enfermedad m&#225;s bajas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; El modelo de regresi&#243;n log&#237;stica mostr&#243; que los pacientes con etapa<span class="elsevierStyleHsp" style=""></span>T avanzada ten&#237;an un mayor riesgo de muerte relacionada con la enfermedad&#44; con un riesgo 4&#46;5<span class="elsevierStyleHsp" style=""></span>veces mayor en pacientes con enfermedad T3 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41; y 6&#46;08 veces mayor en pacientes con enfermedad T4 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;028&#41;&#46; Los pacientes con tumores pobremente diferenciados tuvieron un riesgo de muerte relacionada con la enfermedad 3&#46;16<span class="elsevierStyleHsp" style=""></span>veces mayor que los pacientes con tumores bien o moderadamente diferenciados &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;034&#41;&#46; Tambi&#233;n&#44; la RAP present&#243; un riesgo de muerte relacionada con la enfermedad 2&#46;17<span class="elsevierStyleHsp" style=""></span>veces mayor que RAB &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;027&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se muestra que la sobrevida libre de enfermedad tambi&#233;n fue mayor en pacientes que se sometieron a RAB &#40;82&#46;3&#37;&#41; que en pacientes que se sometieron a RAP &#40;60&#46;5&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">El presente estudio mostr&#243; que la cirug&#237;a RAP por s&#237; misma estuvo asociada con prognosis relacionada a recurrencia&#44; sobrevida general y sobrevida libre de enfermedad en el an&#225;lisis de regresi&#243;n multivariada de Cox&#46; Adem&#225;s&#44; algunos factores estuvieron asociados con peores desenlaces oncol&#243;gicos en dichos pacientes&#58; etapas T y N avanzadas y tumores pobremente diferenciados&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La RAP es considerada la operaci&#243;n est&#225;ndar para el c&#225;ncer de recto distal&#46; Sin embargo&#44; actualmente la RAP se realiza a pesar de no contar con un margen rectal distal suficiente&#44; lo cual deja a los pacientes con un estoma&#44; causando un deterioro en su calidad de vida<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a>&#46; Adem&#225;s&#44; en estudios recientes se muestra que la RAP tiene una tasa de recurrencia local mayor&#44; una tasa de sobrevida m&#225;s baja&#44; una tasa de perforaci&#243;n de tumor m&#225;s alta y una mayor afectaci&#243;n de margen de resecci&#243;n circunferencial que la RAB<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a>&#46; Afortunadamente&#44; la RAP se ha realizado con menor frecuencia debido a las mejoras en las t&#233;cnicas quir&#250;rgicas&#44; la aplicaci&#243;n de RQTN y los cambios en la aceptaci&#243;n de un margen de resecci&#243;n distal de 1<span class="elsevierStyleHsp" style=""></span>cm o menos como l&#237;mite tolerable<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Los conceptos en cirug&#237;a oncol&#243;gica moderna tienen como objetivo lograr m&#225;s que la sola resecci&#243;n curativa de la masa tumorosa rectal&#46; La calidad de vida de los pacientes con c&#225;ncer de recto se ha vuelto un factor en el tratamiento primario y se ha evaluado de igual manera en conjunto con los desenlaces quir&#250;rgicos<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La creciente consideraci&#243;n de la calidad de vida en el tratamiento de c&#225;ncer de recto&#44; los avances t&#233;cnicos en la cirug&#237;a y los tratamientos multimodales con RQTN recientemente han llevado a que las t&#233;cnicas con preservaci&#243;n de esf&#237;nter se apliquen m&#225;s frecuentemente<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">12-17</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En consecuencia&#44; la RAP solo es considerada cuando la resecci&#243;n anterior con preservaci&#243;n de esf&#237;nter no es viable&#46; Adem&#225;s&#44; en reportes recientes se ha indicado que la RAP podr&#237;a estar asociada con recurrencia local y peores desenlaces oncol&#243;gicos<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Sin embargo&#44; la indicaci&#243;n de RAP para pacientes con c&#225;ncer de recto extraperitoneal sigue siendo alta&#44; con un rango del 12 al 47&#37;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">18-24</span></a>&#46; El presente estudio mostr&#243; una tasa incluso m&#225;s alta con 58&#46;1&#37;&#46; El marco temporal del estudio&#44; del 2002 al 2012&#44; fue un periodo en el que los m&#225;rgenes distales y circunferenciales no estaban a&#250;n bien establecidos y las t&#233;cnicas quir&#250;rgicas se fueron refinando gradualmente en nuestra instituci&#243;n&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En una revisi&#243;n sistem&#225;tica recientemente publicada se reportan desenlaces oncol&#243;gicos despu&#233;s del tratamiento de c&#225;ncer de recto de un promedio del 78&#46;6&#37; en la tasa de sobrevida general de 5<span class="elsevierStyleHsp" style=""></span>a&#241;os<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a>&#44; mientras que la tasa de sobrevida general en el presente estudio fue del 66&#46;9&#37; a los 32<span class="elsevierStyleHsp" style=""></span>meses de seguimiento&#46; Debido a que la mayor&#237;a de los estudios incluidos en dicha revisi&#243;n involucraban a pacientes preoperatorios con tumores en etapa TNM y&#47;o pacientes que no se hab&#237;an sometido a radioquimioterapia&#44; los resultados de nuestro estudio no son comparables con los reportados en aquellos resultados&#46; Adem&#225;s&#44; la tasa de c&#225;ncer de recto local avanzado en ese reporte fue del 70&#37;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En el presente estudio&#44; la diferenciaci&#243;n pobre y la RAP fueron identificados como factores independientes de prognosis para la recurrencia local&#46; En varios estudios previos se ha reportado que la etapa<span class="elsevierStyleHsp" style=""></span>N&#44; pero no la etapa<span class="elsevierStyleHsp" style=""></span>T&#44; predec&#237;an la recurrencia local y una sobrevida disminuida<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#44;17&#44;18</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En varios reportes se han mostrado resultados pobres de la cirug&#237;a RAP&#44; con tasas mayores de recurrencia local que con la cirug&#237;a RAB<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a>&#46; La RAP est&#225; asociada con una afectaci&#243;n de margen de resecci&#243;n circunferencial &#40;MRC&#41; mayor&#44; lo cual probablemente se atribuye a una peor enfermedad en pacientes que se sometieron a RAP que en los que se sometieron a RAB&#46; La RAP est&#225; t&#237;picamente indicada en pacientes con peores condiciones locales&#44; como invasi&#243;n de esf&#237;nter o plano interesf&#237;nter afectado&#46; El mal pron&#243;stico en pacientes con etapa patol&#243;gica avanzada puede explicar los peores desenlaces asociados con la cirug&#237;a RAP reportados en estudios previos<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">24-26</span></a>&#46; Sin embargo&#44; en el presente estudio los pacientes que se sometieron a RAB o RAP ten&#237;an etapas<span class="elsevierStyleHsp" style=""></span>T y<span class="elsevierStyleHsp" style=""></span>N similares&#44; pero los desenlaces fueron mejores para la cirug&#237;a RAB que para la RAP&#46; Se ha demostrado previamente que la RAB con EMT es segura para la resecci&#243;n de margen distal&#44; lo cual permite que se preserve el esf&#237;nter y se logren resultados oncol&#243;gicos similares a los de RAP en t&#233;rminos de recurrencia local y sobrevida&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Existen muchos estudios comparativos que investigan los desenlaces oncol&#243;gicos de RAP y RAB&#46; Sin embargo&#44; pocos estudios han comparado los desenlaces oncol&#243;gicos entre RAP y la cirug&#237;a con preservaci&#243;n de esf&#237;nter despu&#233;s de RQTN&#46; En el presente estudio&#44; la tasa de sobrevida general fue del 74&#46;2&#37; para los pacientes tratados con RAB y del 46&#46;5&#37; para los pacientes tratados con RAP&#44; lo cual coincide con estudios previos<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">18&#44;24</span></a>&#46; Wibe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> reportaron que la tasa de sobrevida general de 5 a&#241;os fue diferente para ambos grupos &#40;RAB 68&#37; vs RAP 55&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Law et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> reportaron que la sobrevida era peor en pacientes que se sometieron a RAP que en pacientes que se sometieron a RAB&#46; Estos autores sugirieron que al realizar una RAP puede ser necesaria una resecci&#243;n m&#225;s radical al nivel del tumor&#46; Sin embargo&#44; Chuwa y Seow-Choen<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> se&#241;alaron que los desenlaces oncol&#243;gicos de pacientes que se sometieron a RAP no fueron diferentes a aquellos que se sometieron a RAB&#46; Al contrario de los resultados obtenidos en el presente trabajo&#44; los autores de dicho estudio sugieren que tanto RAB como RAP podr&#237;an tener tasas de morbimortalidad similares&#44; sin comprometer los desenlaces oncol&#243;gicos&#44; cuando son realizadas en una unidad especializada&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">La tasa de recurrencia local en el presente estudio fue peor en el grupo RAP &#40;27&#37;&#41; que en el grupo RAB &#40;12&#46;9&#37;&#41;&#46; Wibe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> tambi&#233;n reportaron que la tasa de recurrencia local a 5<span class="elsevierStyleHsp" style=""></span>a&#241;os era peor en pacientes de RAP que en pacientes de RAB &#40;RAB 10&#37; vs RAP 15&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#46; Tambi&#233;n&#44; Kim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> reportaron que la tasa de recurrencia local fue peor en pacientes que se sometieron a RAP que en pacientes que se sometieron a RAB&#46; Sin embargo&#44; Chuwa y Seow-Choen<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> no observaron ninguna diferencia en la tasa de recurrencia local entre pacientes tratados con RAP y con RAB&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">El presente estudio tuvo varias limitaciones&#46; Primero&#44; debido a que el dise&#241;o fue retrospectivo&#44; el sesgo de selecci&#243;n puede haber afectado los resultados&#44; y factores confusos ocultos pueden haber sido pasados por alto&#46; Otra limitaci&#243;n fue el hecho de que aunque todos los pacientes se sometieron a EMT&#44; el grado de su compleci&#243;n no fue registrado en nuestra base de datos durante la etapa temprana del estudio&#46; En consecuencia&#44; no pudimos reportar la gradaci&#243;n de la calidad de la EMT&#46; Los m&#233;todos de medici&#243;n empleados tambi&#233;n pueden ser responsables de diferencias en las longitudes de resecci&#243;n de m&#225;rgenes y no incluimos el anillo de dona engrapado&#44; lo cual puede haber afectado la longitud del margen distal&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusi&#243;n</span><p id="par0185" class="elsevierStylePara elsevierViewall">Los pacientes con c&#225;ncer de recto distal localmente avanzado que se sometieron a RAP presentaron tasas de sobrevida general y relacionadas con la enfermedad m&#225;s bajas y tambi&#233;n presentaron una mayor tasa de recurrencia que los pacientes que se sometieron a RAB&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; la etapa T avanzada&#44; la afectaci&#243;n ganglionar y la diferenciaci&#243;n pobre estuvieron asociados con la recurrencia local y una menor sobrevida relacionada con la enfermedad&#44; independientemente del procedimiento quir&#250;rgico&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Autores y contribuciones</span><p id="par0195" class="elsevierStylePara elsevierViewall">Nahas S&#46;C&#46;&#58; Concepto del proyecto&#44; creaci&#243;n de la base de datos para la evaluaci&#243;n de los pacientes y revisi&#243;n del manuscrito final&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Nahas C&#46;S&#46;R&#46;&#58; Dise&#241;o de estudio&#44; an&#225;lisis de datos y revisi&#243;n de manuscrito&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Bustamante-Lopez L&#46;A&#46;&#58; Borrador de los textos y revisi&#243;n de la literatura&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Pinto R&#46;A&#46;&#58; Recolecci&#243;n de datos y borrador del manuscrito&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Marques C&#46;F&#46;S&#46;&#58; An&#225;lisis de datos y revisi&#243;n del manuscrito&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Cecconello I&#46;&#58; Autor principal&#44; supervisor de la totalidad del trabajo y revisi&#243;n del documento final&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0225" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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            0 => array:2 [
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              "titulo" => "Introduction and aim"
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              "titulo" => "Tratamiento quir&#250;rgico"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "An&#225;lisis estad&#237;stico"
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              "titulo" => "Consideraciones &#233;ticas"
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          "titulo" => "Discusi&#243;n"
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          "titulo" => "Autores y contribuciones"
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          "titulo" => "Conflicto de intereses"
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          "titulo" => "Bibliograf&#237;a"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2019-02-10"
    "fechaAceptado" => "2019-05-30"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "C&#225;ncer de recto"
            1 => "Sobrevida"
            2 => "Recurrencia"
            3 => "Tratamiento quir&#250;rgico"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Rectal cancer"
            1 => "Survival"
            2 => "Recurrence"
            3 => "Surgical treatment"
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    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a de c&#225;ncer de recto distal &#40;CRD&#41; puede ser llevada a cabo con o sin la preservaci&#243;n de esf&#237;nter&#46; El objetivo del presente estudio fue analizar los desenlaces de dos t&#233;cnicas quir&#250;rgicas en el tratamiento de pacientes con CRD&#58; resecci&#243;n anterior baja &#40;RAB&#41; y resecci&#243;n abdominoperineal &#40;RAP&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se evalu&#243; a pacientes con CRD avanzado que se sometieron a tratamiento quir&#250;rgico entre el 2002 y 2012&#46; Comparamos los desenlaces por tipo de cirug&#237;a &#40;RAB vs RAP&#41; y analizamos las asociaciones de sobrevida y recurrencia con los siguientes factores&#58; edad&#44; sexo&#44; localizaci&#243;n de tumor&#44; ganglios linf&#225;ticos afectados y obtenidos&#44; y afectaci&#243;n de la pared rectal&#46; Se excluy&#243; a pacientes con met&#225;stasis distantes&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a un total de 148 pacientes&#44; de los cuales 78 eran mujeres &#40;52&#46;7&#37;&#41;&#46; El promedio de edad de los pacientes fue de 62&#46;1<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46; Se realiz&#243; radioquimioterapia neoadyuvante en el 86&#46;5&#37; de los pacientes&#46; Ochenta y seis pacientes &#40;58&#46;1&#37;&#41; se sometieron a RAP y 62 &#40;41&#46;9&#37;&#41; a RAB&#46; No se observaron diferencias entre los dos grupos respecto a las caracter&#237;sticas cl&#237;nicas y oncol&#243;gicas&#46; La enfermedad de 87 pacientes &#40;62&#37;&#41; era pT3-4 y en 41 &#40;27&#46;7&#37;&#41; pacientes exist&#237;a afectaci&#243;n ganglionar&#46; En el an&#225;lisis multivariado&#44; solo los tumores con diferenciaci&#243;n pobre &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;026&#41; y la RAP &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41; estuvieron correlacionados con una tasa m&#225;s alta de recurrencia&#46; El tiempo promedio de seguimiento fue de 32<span class="elsevierStyleHsp" style=""></span>meses &#40;16-59&#46;9&#41;&#46; La sobrevida de 5<span class="elsevierStyleHsp" style=""></span>a&#241;os general fue del 58&#46;1&#37;&#46; La tasa de sobrevida de 5<span class="elsevierStyleHsp" style=""></span>a&#241;os fue peor en pacientes que se sometieron a RAP &#40;46&#46;5&#37;&#41; que en pacientes que se sometieron a RAB &#40;74&#46;2&#37;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con CRD localmente avanzado que se sometieron a RAP presentaron una menor tasa de sobrevida y una tasa m&#225;s alta de recurrencia local que los pacientes que se sometieron a RAB&#46; Adem&#225;s&#44; la etapa T&#47;avanzada&#44; la afectaci&#243;n ganglionar y la diferenciaci&#243;n tumoral pobre estuvieron asociados con mayor recurrencia y tasa m&#225;s baja de sobrevida&#44; independientemente del procedimiento quir&#250;rgico&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introducci&#243;n y objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and aim</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Surgery for distal rectal cancer &#40;DRC&#41; can be performed with or without sphincter preservation&#46; The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients&#58; low anterior resection &#40;LAR&#41; and abdominoperineal resection &#40;APR&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated&#46; We compared the outcomes of the type of surgery &#40;APR vs LAR&#41; and analyzed the associations of survival and recurrence with the following factors&#58; age&#44; sex&#44; tumor location&#44; lymph nodes obtained&#44; lymph node involvement&#44; and rectal wall involvement&#46; Patients with distant metastases were excluded&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 148 patients were included&#44; 78 of whom were females &#40;52&#46;7&#37;&#41;&#46; The mean patient age was 61&#46;2<span class="elsevierStyleHsp" style=""></span>years&#46; Neoadjuvant chemoradiation therapy was performed in 86&#46;5&#37; of the patients&#46; APR was performed on 86 &#40;58&#46;1&#37;&#41; patients&#44; and LAR on 62 &#40;41&#46;9&#37;&#41; patients&#46; No differences were observed between the two groups regarding clinical and oncologic characteristics&#46; Eighty-seven &#40;62&#37;&#41; patients had pT3-4 disease&#44; and 41 patients &#40;27&#46;7&#37;&#41; had lymph node involvement&#46; In the multivariate analysis&#44; only poorly differentiated tumors &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;026&#41; and APR &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41; correlated with higher recurrence rates&#46; Mean follow-up time was 32 &#40;16-59&#46;9&#41; months&#46; Overall 5-year survival was 58&#46;1&#37;&#46; The 5-year survival rate was worse in patients that underwent APR &#40;46&#46;5&#37;&#41; than in the patients that underwent LAR &#40;74&#46;2&#37;&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR&#46; In addition&#44; advanced T&#47;stage&#44; lymph node involvement&#44; and poor tumor differentiation were associated with recurrence and a lower survival rate&#44; regardless of the procedure&#46;</p></span>"
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                  \t\t\t\t">70 &#40;47&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;58&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">78 &#40;52&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;507<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>40 a&#241;os o menor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;5&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>41 a 60 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30 &#40;48&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38 &#40;44&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">68 &#40;45&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mayor de 60 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20 &#40;13&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">53 &#40;85&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Etapa T</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;360&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22 &#40;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etapa N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negativo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positivo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#62; 12 ganglios</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;057&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo histol&#243;gico</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tubular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72 &#40;83&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">130 &#40;87&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mucinoso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;6&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diferenciaci&#243;n de tumor</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>40 a&#241;os o menor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#62; 12 ganglios</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo histol&#243;gico</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;374<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tubular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mucinoso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diferenciaci&#243;n de tumor</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;026<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Buena&#47;moderada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">110 &#40;78&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pobre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vivo &#40;n &#61; 86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muerto &#40;n &#61; 62&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;825&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41 &#40;58&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">29&#40;41&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">44&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Femenino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33&#40;42&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>40 a&#241;os o menos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;90&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>41 a 60 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">40&#40;58&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#225;s de 60 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Radio quimioterapia neoadyuvante</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;452<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etapa T</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tubular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mucinoso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diferenciaci&#243;n de tumor</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;050<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Buena&#47;moderada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pobre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49&#46;6&nbsp;\t\t\t\t\t\t\n
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