Rectal endosonography for the visualisation of the anastomosis after anterior resection and its relevance to local recurrence

Early detection of locally recurrent rectal cancer by endosonography

After curative surgery for rectal cancer, the goal of an aggressive surveillance programme is the detection of local recurrence (LR) at an early and potentially curable stage 62 patients (mean age 66.2 years) operated on for rectal cancer were prospectively enrolled in a follow-up study including endorectal ultrasound (EUS), serial CEA levels, digital examination, colonoscopy and pelvic CT. A total of 192 sonographic scans were performed, with a mean of three (range 2-7) for each patient. LR occurred in 11 patients; in all cases this was suggested by EUS. In two patients (18%) other techniques had failed to detect recurrent disease, which was identified solely by EUS. These two were treated radically and the remainder received radiotherapy or other palliative management. Five patients are alive at, on average, 18 months after LR (range 4-26 months). These include both cases treated with salvage surgery and who remain disease free. EUS is a valuable tool in the detection of locally recurrent rectal cancer.

Endoluminal ultrasonography in the follow-up of patients with rectal cancer

One principal aim in follow-up after curative surgery for colorectal cancer is to identify recurrent disease at an early and possibly treatable stage. The major problem for patients with rectal carcinoma is local recurrence, which occurs in 3-30 per cent of cases and carries a 5-year survival rate of less than 5 per cent. Since 1989, in addition to digital and sigmoidoscopic examination, endorectal ultrasonography has routinely been used in the follow-up of patients with rectal cancer. Sixty-six patients (40 men) who had undergone attempted radical surgery for mid- and lower-third rectal cancer were included in the study. The mean age was 68 (range 43-87) years. A total of 190 scans were performed, with a mean of 3 (range 1-9) for each patient. Thirteen (20 per cent) of the 66 patients developed local recurrence; in all cases this was suggested by rectal ultrasonography. Digital examination and rigid sigmoidoscopy failed to detect recurrence in three patients. Four detected recurrences were treated radically; the remaining patients received radiotherapy, palliative transanal resection or laser management because of advanced age or refusal to undergo surgery. Six patients were alive a mean of 21 (range 4-50) months after recurrence. Of these six patients, four were free from disease (three had undergone salvage surgery and one radiotherapy). Postoperative rectal ultrasonography can detect some local recurrences at an early treatable stage. The method is more accurate than digital examination and sigmoidoscopy, and should be used as part of a regular follow-up programme.

Anorectal endosonography in benign anorectal disorders

Anal endosonography is an excellent method of visualising the anal sphincters and the pelvic floor. In particular, defects in the internal and external anal sphincters can be demonstrated. Thickness of the sphincters can also be measured. Fistulas and abscesses can be visualised. The clinical indications for performing anal endosonography are: (i) Faecal incontinence and soiling, to detect a possible sphincter defect. In combination with anorectal function tests (like anal manometry, rectal compliance, EMG and pudendal nerve latency measurements), the cause of faecal incontinence or soiling can be determined. (ii) Fistulae and abscesses, to detect the extension of the lesion in relation to the anal sphincters and deeper structures. (iii) Constipation, to exclude a hypertrophic sphincter. (iv) Pre- and postoperative in ileo-rectal and ileo-anal anastomosis, to demonstrate or exclude anal sphincter defects. (v) Pre- and postoperatively in all patients who undergo anorectal surgery to be informed about possible anal sphincter abnormalities. Anorectal function tests should also be performed when anal endosonography is done in evaluating possible faecal incontinence. For scientific interest all anorectal disorders like haemorrhoids, fissures and inflammatory bowel disease offer challenges to anal endosonography. In conclusion, anal endosonography is an easy to perform test of great importance in patients with anorectal pathology, especially in patients with faecal incontinence or soiling and patients who need anorectal surgery to be informed about possible sphincter defects.

Intraluminal ultrasound of rectal tumours: a prerequisite in decision making

The use of intraluminal ultrasound (IUS) as a staging technique was evaluated in 58 patients with a rectal tumour. Thirty-four patients had a rectal carcinoma, four had a local recurrence after a previous anterior resection and 20 other patients had a villous adenoma. IUS assessment of rectal wall invasion, infiltration into adjacent organs, and the presence of perirectal lymph node involvement was compared with the definitive histological findings. In 90% of all patients the pre-operative local tumour staging was predicted correctly. In 38 patients with a rectal carcinoma the overall accuracy for the T grade was 84%. The sensitivity for the detection of perirectal fat infiltration was 91%, with a specificity of 70% and a negative predictive value of 78%. The accuracy in predicting direct infiltration into adjacent organs was 100% (n = 5). In the four patients with a local recurrence, the diagnosis was suspected by means of IUS and confirmed by biopsies. Extraluminal tumour growth was predicted correctly in all cases, with extension into the coccygeal bone in one patient. IUS identified lymph nodes in 29 of 38 cases, with a sensitivity of 57% and a specificity of 76%. All 20 villous adenomas were correctly staged as non-infiltrative tumours. After transmural excision, three adenomas proved to contain a completely removed T1 carcinoma. IUS is the most accurate tool in predicting the depth of local tumour invasion and needs a place in the preoperative screening programme in patients with a rectal tumour, as well as in the postoperative follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)