Use of circular stapling gun with peranal insertion of anorectal purse-string suture for construction of very low colorectal or colo-anal anastomoses

End-to-end versus end-to-side anastomosis for low anterior resection: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Numerous randomized controlled trials comparing end-to-end and end-to-side anastomoses after low anterior resection have been performed. Rates of anastomotic leakage and overall postoperative morbidity, as well as reported quality of postoperative bowel function, vary across individual studies. As such, this study meta-analyzes pooled data comparing end-to-end and end-to-side anastomosis after low anterior resection in terms of anastomotic leak rate and postoperative bowel function.

METHODS

A search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials was performed. Articles were included if they were randomized controlled trials that compared end-to-end and end-to-side anastomosis after low anterior resection for benign or malignant disease. The primary outcome was anastomotic leak rate. A pairwise meta-analysis was performed using inverse variance random effects.

RESULTS

From 1,452 citations, 6 randomized controlled trials with 270 patients undergoing end-to-end anastomosis (45.9% female, mean age: 63.5 years) and 268 patients undergoing end-to-side anastomosis (52.4% female, mean age: 64.0 years) met inclusion criteria. Patients undergoing end-to-side anastomosis had a significantly lower rate of anastomotic leak (RR 0.37, 95% CI 0.15-0.93, P = .04, I²=0%). There were no differences in rate of anastomotic stenosis (RR 1.03, 95% CI 0.21-5.19, P = .97) or overall postoperative morbidity (RR 0.60, 95% CI 0.33-1.07, P = .08). Narrative review of postoperative bowel function demonstrated evidence of improved Wexner scores for 6 months postoperatively in patients undergoing end-to-side anastomosis.

CONCLUSION

End-to-side anastomosis significantly reduces the risk of anastomotic leak after low anterior resection. Additional prospective trials are warranted to confirm the findings of this review and to contribute to the growing evidence-base aimed at optimization of bowel function after low anterior resection.

Quality of life with or without sphincter preservation for rectal cancer

AIM

The aim of this investigation was to examine quality of life after surgical treatment for low rectal cancer.

METHOD

This was a population-based, cross-sectional study on quality of life in patients treated for rectal cancer from 2001 to 2007. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and a single question on the impact of bowel/stoma function on quality of life were sent to patients who had undergone abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer with tumours below 10 cm from the anal verge.

RESULTS

Informative answers were obtained from 898 patients (87%). EORTC QLQ-C30 outcomes were very similar for APE and LAR patients in univariate analysis. When adjusted for neoadjuvant radiotherapy and gender, multivariate analysis showed that LAR patients had lower global health status (OR 1.32, 95% CI 1.03; 1.68, P = 0.026) and higher occurrence of constipation (OR 0.47, 95% CI 0.32; 0.69, P < 0.001) and diarrhoea (OR 0.47, 95% CI 0.35; 0.64, P < 0.001). Analysis of the anchor question showed that LAR patients had significantly higher negative impact of bowel function on quality of life in both univariate (OR 3.38, 95% CI 2.62; 4.37, P < 0.001) and multivariate analysis (OR 3.71, 95% CI 2.86; 4.83, P < 0.001) compared with APE.

CONCLUSION

For patients with low rectal cancer, we found LAR patients had worse global health status and problems with diarrhoea and constipation compared with APE patients.

Sphincter-saving surgeries for rectal cancer: A single center study from Kashmir

Summary and Background Data:

The goals in the treatment of rectal cancer are cure, local control, and preservation of sphincter, bladder and sexual function. Surgical resection using sharp mesorectal dissection is important for achieving these goals.

Objectives:

The current treatment of choice for carcinoma rectum is sphincter saving procedures, which have practically replaced the previously done abdominoperineal resection. We performed a study in our institute to evaluate the surgical outcome and complications of rectal cancer.

Materials and Methods:

This prospectivestudy included 117 patients, treated for primary rectal cancer by low anterior resection (LAR) from May 2007 to December 2010. All patients underwent standard total mesorectal excision (TME) followed by restoration of continuity.

Results:

The peri-operative mortality rate was 2.5% (3/117). Post-operative complications occurred in 32% of the patients. After a median follow up of 42 months, local recurrences developed in 6 (5%) patients and distant metastasis in 5 (4.2%). The survival rate was 93%.

Conclusion:

The concept of total mesorectal excision (TME), advances in stapling technology and neoadjuvant therapy have made it possible to preserve the anal sphincter in most of the patients. Rectal cancer needs to be managed especially in a specialized unit for better results.

Validation of the International Study Group of Rectal Cancer definition and severity grading of anastomotic leakage

BACKGROUND

The International Study Group of Rectal Cancer (ISREC) has proposed a generally applicable definition and severity grading of (AL) after sphincter-preserving resection of the rectum. This work has been carried out to test for validity.

METHODS

A total of 746 patients who were identified from a prospective rectal cancer database underwent sphincter-preserving anterior resection of the rectum between October 2001 and January 2011. The incidence and severity of AL was determined using the criteria established by the ISREC. Patients with AL were categorized according to the ISREC scheme. The clinical outcomes were analyzed and compared between the groups.

RESULTS

The overall AL rate was 7.5% (56/746). The 56 patients with AL were distributed among the different groups as follows: Grade A, 16%; grade B, 23%; and grade C, 61%. Compared with the grade A patients, grades B and C patients had significantly elevated serum C-reactive protein levels (P < .01). None of the grade A patients were transferred to the intensive care unit (ICU). Their further hospital stay was uneventful. The length of stay in the ICU was significantly longer for grade C patients compared with grade B patients (P < .001). The median hospital stay of grade C patients was significantly longer than that of grades A and B patients (P < .001).

CONCLUSION

The definition and severity grading of AL after anterior resection of the rectum proposed by the ISREC provides a simple, easily applicable, and valid classification. Using this classification system may facilitate comparison of results from different studies on AL after sphincter-preserving rectal surgery.

Colorectal anastomosis after laparoscopic low anterior resection with total mesorectal excision: a difficult problem made simple

Laparoscopic anterior resection with total mesorectal excision for middle and lower third rectal cancer remains a difficult operation, in particular, in male patients with a narrow pelvis and bulky mesentery. In this type of patient, the available staplers do not allow an easy transection of the rectum close to the pelvic floor. A new approach that uses instruments (dilator, obturator, and pursestring anoscope) specifically designed for the technique of stapled hemorrhoidopexy and a common circular stapler can overcome all these issues.

Mechanical-stapled versus hand-sutured anastomoses in billroth-I reconstruction with distal gastrectomy

PURPOSE

In June 2000, we started performing mechanical-stapled anastomosis (MSA) for Billroth-I reconstruction (B-I) in distal gastrectomy. Thus, we performed a retrospective study to compare the clinical outcome of MSA and conventional hand-sutured anastomosis (HA).

METHODS

We evaluated 103 patients who underwent a B-I reconstruction. The data we collected included operative time, operative blood loss, time until oral intake, postoperative hospital stay, and anastomotic and general complications. We also examined the remnant stomach by endoscopy and classified it according to the Residue, Gastritis, Bile (RGB) criteria.

RESULTS

The operative time was significantly shorter with MSA than with HA, but there were no other significant differences between the two groups. The RGB classification showed that there was more residual stomach content after MSA than after HA. The incidence of gastritis and bile reflux was not significantly different between the two procedures.

CONCLUSION

The operative time for B-I reconstruction with distal gastrectomy was significantly shorter with MSA than with HA. While there were no significant disadvantages in the incidence of complications associated with MSA compared with HA, MSA resulted in more residue in the remnant stomach. The findings of this study showed the advantages and disadvantages of MSA, and suggest that MSA and HA are equivalent as anastomotic procedures in B-I reconstruction.

Dual endoscopic-assisted endoluminal colostomy reversal: a feasibility study

BACKGROUND

Emergent colostomies are associated with increased morbidity related to second closure operations. The purpose of this canine pilot study was to create a minimally invasive procedure that would reduce the time interval and morbidity involved with colostomy reversals after left colon end colostomies.

METHODS

Six mongrel dogs underwent modified laparoscopic Hartmann's procedures in which the stapled end of the rectal stump was approximated to the left colon proximal to the stoma. After 1 week, they underwent an endoluminal colostomy reversal with a computer-mediated, circular stapling device and varying anvil insertion methods. Variables recorded included anvil insertion technique and feasibility, OR time, complications, and number of days to first meal and bowel movement. A contrast enema performed 1 week post colostomy reversal ruled out anastomosis leaks and stenosis. The dogs were euthanized and subjected to necropsy.

RESULTS

Of four anvil insertion techniques tested, the most feasible employed a large-bore needle to perforate through the stapled end of the Hartmann pouch into the lumen of the left colon. Simultaneous endoluminal views of the rectal stump with a sigmoidoscope and the left colon lumen with an endoscope permitted a controlled and safe needle puncture. Through the needle, a guide wire was inserted to withdraw the anvil via the colostomy into place. A transanally inserted stapler was then married to the anvil under fluoroscopic guidance, thus completing the anastomosis. The colostomy was then taken down and transected at the level of the colocolostomy. Average operating time was 126 min (range 90-180), diet was tolerated within 1.5 days, and average number of days to first bowel movement was 2.5. The absence of stenosis, leaks, and inadvertent visceral injuries confirmed feasibility.

CONCLUSIONS

In this canine model, a dual endoscopic-assisted colostomy reversal with a computer-mediated, circular stapling device is feasible. Using this technique, colostomy reversals can possibly be performed 1 week post-colostomy without entering the peritoneal cavity, thus reducing the number of invasive operations and subsequent morbidity required to manage emergent colon perforations.

Anastomotic integrity and function: role of the colonic J-pouch

Since the colonic J-pouch with a colo-anal anastomosis was first introduced in 1986, many reports have shown the superiority of this design as compared to a "straight" colo-anal anastomosis. These advantages have been demonstrated in retrospective, prospective, and prospectively randomized reports. Furthermore, these attributes are realized for at least 12 and possibly more than 24 months after surgery.

All mechanical low rectal anastomosis in children

PURPOSE

The aim of this study is to demonstrate the feasibility and usefulness of mechanical suturing in children for low rectal anastomosis.

METHODS

The study group includes 31 children operated on from January 1993 to July 1996 by the same senior surgeon, performing the modified Duhamel procedure for Hirschsprung's disease in 17 children, intestinal neuronal dysplasia in seven, and the Knight-Griffen procedure in seven pediatric patients with chronic ulcerative colitis.

RESULTS

In all the cases the technique of "viscero-synthesis" was performed using the mechanical stapler. A circular stapler has been used for the end-to-end and the end-to-side anastomosis between the anal canal or the back wall of the rectum with the pulled viscus, while a linear endoscopic stapler (GIA) has been used for the consolidation of the rectocolic wall in the modified Duhamel technique.

CONCLUSIONS

The results obtained demonstrate that the mechanical staplers in children are safe and effective in low rectal anastomosis, sparing operative time and reducing the risk of anastomotic dehiscence; however, the size of circular instruments limits its use in neonates and small infants.

Advances in rectal cancer surgery in Japan

A review of advancement of rectal cancer surgery in Japan is presented. The standard operation for rectal cancer was altered in the 1960s from abdominoperineal resection to the pull-through technique and the handsewn anterior resection in the 1970s, and it became the stapled anterior resection in the 1980s. Today, more than 75 percent of rectal cancers are treated with sphincter-preserving anterior resections, and the remaining 20 percent by abdominoperineal resections. Colonic J-pouch is used with anastomoses involving very low anterior rectal resection for cancers. In the late 1970s, a method of dissecting extended pelvic nodes was adopted to decrease local recurrence. However, extended dissection has been applied to only T3 and T4 cancers of the lower rectum because of postoperative dysfunction of pelvic organs. This was caused by injury to the pelvic nerve plexus, thus lowering the quality of life of the patients. Since the middle of the 1980s, the autonomic nerve-preserving operation attracted surgeons' attention because it prevented these dysfunctions from occurring as a result of the treatment of cancer in the upper rectum and for T1 or T2 cancers in the lower rectum. In this article, recent advances in rectal cancer surgery in Japan are reviewed.

Kumacone II: an adapter to aid in the placement of a purse-string suture in very low anterior rectal resection

We have designed an adapter called the "Kumacone II", being a bottle-shaped rubber device which greatly aids in placing a purse-string suture, even at the lowest level near the anorectal junction of the rectum. When this adapter is used, performing the anastomosis is much less time-consuming and not as much training is needed as for low anterior resection using conventional manual suturing. In a clinical study, the incidence of leakage and incontinence was nil in five out of five patients.

Triangulating stapling technique: an alternative approach to colorectal anastomosis

The triangulating stapling technique was employed to perform colorectal anastomosis in 259 patients. In 220 patients, the anastomosis was performed between the colon and nonperitonealized rectum. This anastomotic technique is safe and reliable and is an effective alternative to a circular stapling device, with minimal morbidity. The incidence of leak rate is comparable to anastomoses created by a circular stapling device. The main advantage seems to be the very low incidence of anastomotic stenosis.

Local recurrence after anterior resection for rectal cancer using a double stapling technique

Fifty-five patients of mean age 69 (range 41-96) years with rectal cancer (Dukes' A:B:C, 11:24:20) underwent anterior resection using a double stapling technique under the care of one consultant surgeon between 1983 and 1988. The mean distance of the anastomosis from the anal margin was 7.2 (range 4-13) cm. The clinical leak rate was 9 per cent (five patients). There were three postoperative deaths from pulmonary embolism, lower limb ischaemia and renal failure. On prospective follow-up, 35 patients had no evidence of local or systemic cancer a median of 32 (range 24-84) months after operation; seven have died from unrelated diseases and ten from metastatic cancer. Pelvic recurrence, in four patients at 9, 11, 12 and 50 months, has occurred only in association with widespread metastasis. These results suggest that the theoretical risks of an increase in the local recurrence rate of rectal cancer after resection using a double stapling technique are not substantiated.

Improving survival rates for patients with colorectal cancer

Between 1 January 1984 and 31 December 1990, 575 patients were operated on for colorectal cancer. The surgical procedure was performed consistently and no patients were lost to follow-up. Almost half of the patients (284 of 575) had tumours of stage I or II, with 5-year survival rates over 90 per cent. After extending the resection margins in 28 cases of colonic carcinoma there has been no case of tumour recurrence. The overall 5-year survival rate for patients with colonic carcinoma was 81 per cent. Complete resection of the mesorectum was mandatory for rectal resection. One-third of the carcinomas in the lower third of the rectum could be resected with maintenance of bowel continuity and an abdominoperineal resection avoided. Not only was the tumour recurrence rate in the former patients lower (10.5 per cent) compared with that in those undergoing abdominoperineal resection (14.3 per cent) but the 5-year survival rate at 90 versus 52 per cent was significantly higher. The overall 5-year survival rate for patients with rectal carcinoma was 71 per cent.

Rectovaginal fistula: complication of low anterior resection

Three hundred of 990 active members (30 percent) of The American Society of Colon and Rectal Surgeons responded to a survey regarding the incidence of rectovaginal fistulas following low anterior resection. A total of 57 patients were reported to have had postoperative rectovaginal fistulas; of these, 53 had circular-stapled anastomoses. Patient characteristics, surgeon's experience, technical methods, pathology, and methods of treatment were surveyed. As lower resections for rectal sparing are attempted, this emerging complication must be recognized and avoided.

Low anterior resection of the rectum using a double stapling technique

Using a double stapling technique in 30 patients, anterior resection of the rectum was attempted for low rectal carcinoma (n = 28), giant rectal adenoma (n = 1) and radiation-induced rectal stricture (n = 1). There were three emergency operations. The rectum was stapled transversely more than 3 cm below the tumour using the adjustable-angle linear stapler (Roticulator). Colorectal or coloanal anastomoses were constructed using the EEA circular stapler introduced per anum through the anorectal stump staple line. Ten coloanal and 19 low rectal anastomoses were achieved. A protecting transverse loop colostomy was fashioned in one patient with coloanal anastomosis who developed a vaginal tear during the procedure. In one patient technical failure necessitated conversion to abdominoperineal excision of the rectum. All staple rings and resection margins were intact and free from tumour. There were two clinical anastomotic leaks, both treated successfully with a defunctioning transverse loop colostomy. One patient developed a small infective pelvic haematoma 2 weeks after surgery which required drainage. Hospital stay ranged from 6 to 15 days (mean 8 days). Continence was normal in all patients at 8 weeks. One soft coloanal anastomotic stricture required dilatation. No recurrences have been detected during a follow-up of between 10 and 22 months.

The triple-stapled colonic anastomosis

This study reports the preliminary results of a new totally stapled end-to-end colonic anastomosis in 11 dogs. This "triple-stapled" end-to-end anastomosis was performed with one circular staple line and two linear staple lines, eliminating the need for a colotomy or purse-string suture. The fact that the anvil and anvil stem of a new circular stapling device (Premium EEA) can be detached from the frame of the instrument allows the anvil stem to be brought out through the proximal linear stapled colon. The trocar mounted on the main stem of the circular stapler allows the stem of the main device to be brought out through the distal staple line. Thus, a totally stapled colonic anastomosis is created after mating the anvil stem and main stem of the instrument. The new anastomosis was evaluated radiographically and at necropsy. The use of this technique resulted in no clinically detectable leaks, suggesting that it may facilitate the performance of anterior resections in humans.

Survival and complications after radical surgery for carcinoma of the rectum

The results of 164 abdominoperineal resections and 87 anterior resections carried out between 1972 and 1985 for cancer of the rectum were reviewed, assessed, and compared. The problems with anterior resection included a 1.1% hospital mortality and a 5.4% anastomotic failure rate in the 73 manual sutures and 28.5% in the 14 mechanical sutures; recurrence rate was 15.4% and the global 5-year-survival was 62%. There was no mortality in the Miles series; the recurrence rate was 4.8% and the 5-year-survival rate was 53.5%. Urogenital complications after Miles were found in 86.9%: urinary alone 10.8%, sexual alone 19.5%, both 56.5%.

Sphincter-saving procedures for distal carcinoma of the rectum

Methods of sphincter preservation were developed more than a century ago. Combining these techniques with adequate anterior resection has permitted the resurrection of sphincter-saving procedures that are currently being applied in the therapy of cancer at every level of the rectum. Although Miles' abdominoperineal resection still remains the "gold standard" for the treatment of low rectal neoplasms, restorative resection may now be possible with equivalent oncologic disease control and survival. Further, current trends also suggest that the abdominoperineal resection is being used less frequently in the treatment of most rectal cancers and is being replaced with sphincter-preserving techniques that afford excellent functional results. In this review, the pertinent anorectal anatomy, current issues, and sphincter-saving surgical techniques presently available for the treatment of distal cancers of the rectum are presented.

Functional and oncologic results after coloanal anastomosis for low rectal carcinoma

Thirty-five patients who had adenocarcinoma of the middle third of the rectum were treated by resection and coloanal anastomosis. The aim of this study was to assess functional and oncologic results of an original technique of coloanal anastomosis. There was no operative mortality, and operative morbidity consisted of seven anastomotic leaks with two failures. Among 31 patients assessed for functional results only one had unsatisfactory results. Good continence was obtained within a few weeks for the 30 patients who had satisfactory results. No patients were lost to follow-up, which was over 5 years in 24 patients (68%). The 5-year survival rate was 64%, identical to that for other series.

The double stapling technique for low anterior resection of rectal carcinoma

The double stapling technique (TA-55 and EEA staplers) was used to perform low anterior resections for rectal carcinomas in 79 patients (49 men, 30 women). The mean age was 66 years (range, 38 to 85 years). Curative resections were performed in 68 patients, and palliative resections in 11 patients. The mean level of the cancer from the dentate line was 9 cm (range, 5 to 16 cm). The mean follow-up has been 29 months (range, four to 58 months). Perioperative mortality was 2.5 percent (two patients). Technical problems related to the stapling technique occurred in 6 percent (five patients). The clinical anastomotic leak rate was 8 percent (six patients). There were 11 local recurrences among 68 curative resections (16 percent). Local recurrence according to individual surgeon showed marked variability (range, 0-43 percent, P greater than 0.05). There were no differences in location, differentiation, or stage in those that recurred. The mean distal resection margin for the recurrent cancer group was 3.0 cm and for the nonrecurrent group, 2.9 cm. Disturbances of continence were seen commonly (56 percent) in the first three months after surgery, but 85 percent of patients became fully continent with an acceptable bowel habit at later follow-up. The double stapling technique is useful for the restorative resection of suitable mid and low rectal cancers. The anastomotic leak rate, local recurrence rate, and functional results are acceptable.

Carcinoma of the rectum: current management

In recent years, various approaches have been used to improve survival and the quality of life in patients after surgical treatment of rectal carcinoma. These approaches include earlier detection, sphincter-saving procedures, and adjuvant therapy, intraoperative therapy for locally advanced tumors, and a more aggressive approach for locally recurrent or distal but isolated spread of the disease.

Peranal coloanal anastomosis following low anterior resection for rectal carcinoma

Since 1978, 41 patients (12 percent of all restorative operations) have undergone peranal coloanal reconstruction following anterior resection (LAR) for cancers of the midrectum. Twenty-seven patients (66 percent) were men and 14 patients (34 percent) were women (mean, 58.8 years). The mean distance of the primary tumor from the anal verge was 6.7 cm and 50 percent of the primary tumors were considered highly mobile. In 29 patients, a hand-sewn anastomosis was performed between the colon and the dentate line. In the 12 most recent patients, the anastomosis was performed using a circular stapling instrument. A diverting colostomy should be employed in all cases and is closed approximately three months later. There has been no operative mortality. Morbidity included anastomotic separation (two patients), minor anastomotic defects (three patients), pelvic sepsis (two patients), and bacteremia of unknown origin (two patients). Where fecal diversion was employed, there were no instances of anastomotic leak. Two patients with hemorrhage were returned to the operating room. Thirty-seven of the 41 patients underwent curative resections. Thirty-three percent of the patients had Dukes' C lesions. With a median follow-up of 31 months for the curative resections, 73 percent remain free of disease. Sixty-four percent of evaluable patients have either excellent or good anorectal function nine to 12 months after colostomy closure. Of 26 operations performed by one surgeon, 22 patients (85 percent) are currently evaluable. Nineteen (86 percent) of the 22 have normal or near-normal bowel function. Four guidelines for performing a functionally successful operation are presented. Coloanal reconstruction following LAR, were pull-through operations were previously required, is an excellent sphincter-preserving operation. The functional results one year after the operation are gratifying, with the majority of patients leading an active life with normal bowel function.

Experience with stapling in rectal surgery

This review evaluates the use of the circular stapling device for the creation of colorectal anastomoses. It emphasizes the meticulous attention to detail that is needed to minimize intra- and postoperative complications.

Varieties of stapled anastomoses in rectal resection

This article presents numerous illustrations that show a variety of techniques for the restoration of intestinal continuity after low anterior resection. The conclusion is that, at extremely low levels, the EEA stapler anastomosis can be securely performed at levels at which manual anastomosis would not be possible.

EEA stapler for mid-rectum carcinoma. Review of recent literature and own initial experience

Over a three-year period, 1980-82, 79 per cent of our patients with rectal cancer were treated with the intention of cure, and sphincter-saving procedures were performed in 62 per cent of these cases. This report concerns 21 patients with mid-rectum cancer operated on with low anterior resection and extraperitoneal EEA-stapled anastomosis. Nine patients had Dukes' stage A tumors, seven had stage B, and five had stage C tumors. An 86-year-old woman died in the sixth postoperative week, and a 74-year-old man died after 20 months with a probable recurrence. Nineteen patients are currently alive 4 to 40 months post-operatively, with no overt signs of recurrence. We cannot confirm recent alarming reports on a significant incidence of early local recurrence. Routine Gastrografin enemas were performed and offered very little in terms of clinical guidance. Significant anastomotic leakage occurred in four patients, although without clinical symptoms or the need for fecal diversion. Despite initially intact anastomoses in 13 patients, pelvic sepsis with late dehiscence developed in three, all of whom required fecal diversion. The clinical leak rate was thus 3 of 21, 14 per cent, and the total incidence of leakage 7 of 21, 33 per cent. We performed routine colostomy on the first three patients but, in retrospect, believe this was unneccessary. Only one of the 19 survivors still has a colostomy, due to a benign anastomotic stricture. We consider anterior resection of mid-rectum carcinoma with EEA-stapled anastomosis a highly feasible procedure, the curative potential of which, however, can be established only by long-term follow-up studies.

Abdominosacral resection for midrectal cancer. A fifteen-year experience

From 1966 to 1981, 646 patients underwent resection for primary adenocarcinoma of the rectum by one surgeon (S.A.L.) in one hospital. The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (ASR) in 320 patients, abdominosacral resection (ASR) in 175 patients, and abdominoperineal resection (APR) in 151 patients. The operative mortality rate was 2% following each of the operations. Anastomotic complications occurred in less than 2% after AR and in 9.7% after ASR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 419 of 427 patients treated from 1966 to 1976. Five-year survival for curative resection (no distant metastases) was 66.2% after AR (129/195), 62.9% after ASR (56/89), and 43.4% after APR (33/76). For patients with no tumor in lymph nodes, survival rates were 73.9% in AR, 75% for ASR, and 59.5% for APR. With involvement of regional lymph nodes, survival fell to 45.2% in AR, 37.9% for ASR, and 17.7% for APR. Pelvic recurrence was detected in 13.3% after AR, 14.6% after ASR, and 13.2% after APR. The authors believe that for midrectal cancer, ASR is the most reliable sphincter-saving procedure. It affords maximum exposure for wide resection of the tumor and safe anastomosis without disrupting the anal sphincters and their innervation. Sphincter preservation can be consistently preserved with no apparent increase in the risk of local recurrence or death from cancer.

Double stapling technique for low anterior resection

A report is given on 26 patients (18 men and 8 women) undergoing low anterior resection for carcinoma of the rectum, using both the TA 55 and EEA staplers. The average age was 65 years (range, 45 to 92 years). The preoperative level of the lesion from the anal verge averaged 9.8 cm (range, 4 to 17 cm). All had well-differentiated or moderately well-differentiated lesions. All lesions were removed using the following technique. The TA 55 stapler was placed across the lower rectum at the distal resection margin. The EEA stapler was introduced into the rectum with the anvil removed. The shaft was then passed through the rectum stump either through or immediately adjacent to the staple line. The anvil was refitted and the anastomosis completed between the more proximal colon and the rectal stump. A defunctioning colostomy was employed in only one patient. There has been no mortality. Follow-up has been 2 to 16 months, and there has been no early recurrence. The postoperative level of the anastomosis averaged 5.5 cm (range, 2 to 11 cm). Stapler-related complications occurred in three patients. One of these patients developed a postoperative anastomotic leak, which necessitated a defunctioning colostomy. Two anastomotic strictures occurred following either an anastomotic leak or postoperative radiation therapy. Early incontinence to gas, night-time anal soilage, and urgency occurred in eight patients (30 per cent). These symptoms improved or disappeared within three months following operation. The authors' preliminary experience has shown the double stapling technique to have definite advantages. It obviates the use of lower purse-string suture and permits a lower and easier anastomosis. It avoids the problem of disparity of sizes of the two ends of the bowel. The rectum is not opened and fecal spillage is minimized. To date, results have been good without excessive complications.

Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices

Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1) coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy.

Local recurrence following curative resection for carcinoma of the rectum

One hundred ninety-three patients had curative resections for carcinoma of the rectum between January 1971 and December 1979. Nineteen patients developed local recurrence (9.8 per cent): 5/95 after abdominoperineal excision (5.2 per cent) and 14/98 after anterior resection (14.3 per cent). There was no difference in the overall survival rate between the two operations, but there was a trend toward decreased survival for patients who developed local recurrence. Metastatic spread to the lymph nodes increased the risk of local recurrence.

EEA stapler in low anterior anastomosis

Preservation of the anal sphincter is a goal of all surgeons treating colorectal malignancies. In the hands of many, transsacral and low anterior resections with end-to-end anastomosis have been associated with high morbidity and leakage. The EEA stapler represents an alternative in re-establishing bowel continuity. Fifty-eight patients with adenocarcinoma of the rectum were treated over a three-year period at Roswell Park Memorial Institute. Forty-nine procedures judged to be curative and nine, palliative. All patients had an EEA stapler introduced through the anus. No protective colostomies were needed. No case of clinically significant anastomotic leakage was seen. Minor spotting or bleeding was documented, but no patient required blood transfusions. Two patients developed constipation; 16 patients had temporary soiling, two had prolonged soiling. Frank incontinence was not observed. The EEA stapler is an evolutionary instrument derived from the Russian PKS model. It is safe, reliable, and simple to operate. With adequate training of the surgeon, precious time can be saved. Intraoperative sigmoidoscopies, as well as postoperative barium enema examinations, were not needed. Gaps in the stapled anastomotic line (when present) were easily repaired. It is too early to tell whether anastomotic and local recurrence rates will increase, as more sphincter-saving procedures are performed. Five-year follow up is crucial to establish criteria for the use of the EEA stapler.

A prospective study of bladder function before and after sphincter-saving resections for low carcinoma of the rectum

The effects of sphincter-saving resections for carcinoma of the rectum on bladder function were studied prospectively. Twenty-seven patients, each acting as his or her own control, were studied before, shortly after and 9 months after operation by means of pressure/flow filling and voiding cystometry. After operation there was a significant and lasting increase in the residual volume of urine and a temporary decrease in the compliance of the bladder. There was a statistically significant decrease in detrusor contraction pressure after operation, which persisted throughout the period of study. This was probably due to partial denervation of the bladder. Four patients had signs of total or almost total denervation of the bladder. There was a significant correlation between proximity of the tumour to the anal verge and risk of damage to the nerve supply to the bladder. Thus sphincter-saving resections of the rectum for carcinoma are associated with a significant risk of bladder denervation. Many of the "minor" symptoms of bladder dysfunction which develop after this procedure are due to partial denervation of the bladder.

Five years' experience in stapling the oesophagus and rectum

In the 5-year period from 1976 to 1980, 143 anastomoses were performed using circular stapling devices. In 2 further cases, anastomosis was attempted but failed and operation was completed by orthodox methods. There were 101 oesophageal anastomoses; 70 of these were transections in patients with oesophageal varices and 31 were either oesophagogastric or oesophagojejunal in nature, mainly following excisional cancer surgery. The remaining 42 patients had colorectal anastomoses following anterior resection of the rectosigmoid. Initial results in a follow-up period from 2 months to 5 years have been encouraging. There were 3 cases of complete anastomotic dehiscence and 4 cases of leakage. Stricture formation occurred in 10 per cent of patients but was easily controlled in the majority of cases.

Anastomosis with EEA stapler after anterior colonic resection

The end-to-end anastomosis by stapling for left colonic and rectal resections is proving to be a relatively safe and fast procedure. Results of a survey of the American Society of Colon and Rectal Surgeons reveals 15.1 per cent intraoperative complications, 3.7 per cent early postoperative complications, 0.5 per cent deaths, and 13.8 per cent late complications. The majority of late complications, stenosis and incontinence, were either subclinical or transient for most patients. Technique and prevention of complications are stressed.

A modified circular stapler for gastrointestinal anastomosis

A circular stapler, which avoids the use of a purse-string suture, is described. The gut to be anastomosed is kept in position by a series of hooks. To avoid anastomotic bleeding two rows of B-shaped staples are inserted. The instrument is loaded manually with individual staples to reduce the cost. Experience with oesophageal anastomoses in 40 dogs showed that bleeding did not occur from the suture line and that there was only one leak from the anastomosis. Late stricture formation occurred in 1 dog.

Randomized prospective evaluation of the EEA stapler for colorectal anastomoses

A randomized, prospective study should be done to evaluate any new procedure or instrument. Our experience with the end-to-end anastomosis (EEA) stapler suggests that an anastomosis can be created in a shorter time than is required for the traditional hand-sewn technique. This difference is even greater when the anastomosis is technically difficult and located deep within the pelvis. There appears to be little difference in the security of a hand-sewn anastomosis compared with that of stapled anastomosis. Postoperative complications appear similar. With the stapler, however, there is an increased risk of intraoperative complications that are not apparent with the traditional hand-sewn technique. These include rectal tears and anastomotic defects. It appears that the EEA stapler can save as many as 12 percent of rectums that otherwise might have to be removed because of technical inability to perform an anastomosis.

An alternative technique of inserting the distal purse-string suture for the E.E.A. stapling device in a low anterior resection

A new technique of inserting the distal purse-string suture for the E.E.A. stapling device in a low anterior resection of the rectum is described. The technique is simple and time saving, and does not require any special instruments.