Sphincter saving rectum resection is the standard procedure for low rectal cancer

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer

Introduction

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

Methods

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

Results

Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework.

Conclusion

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.

Functional outcome and quality of life following treatment for rectal cancer

Introduction Over the last decades, treatment for rectal cancer has substantially improved with development of new surgical options and treatment modalities. With the improvement of survival, functional outcome and quality of life are getting more attention.

Study objective To provide an overview of current modalities in rectal cancer treatment, with particular emphasis on functional outcomes and quality of life.

Results Functional outcomes after rectal cancer treatment are influenced by patient and tumor characteristics, surgical technique, the use of preoperative radiotherapy and the method and level of anastomosis. Sphincter preserving surgery for low rectal cancer often results in poor functional outcomes that impair quality of life, referred to as low anterior resection syndrome. Abdominoperineal resection imposes the need for a permanent stoma but avoids the risk of this syndrome. Contrary to general belief, long-term quality of life in patients with a permanent stoma is similar to those after sphincter preserving surgery for low rectal cancer.

Conclusion All patients should be informed about the risks of treatment modalities. Decision on rectal cancer treatment should be individualized since not all patients may benefit from a sphincter preserving surgery “at any price”. Non-resection treatment should be the future focus to avoid the need of a permanent stoma and bowel dysfunction.

Laparoscopic Total Mesorectal Excision for Ultralow Rectal Cancer with Transanal Intersphincteric Dissection as a First Step: A Single-surgeon Experience

Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility of laparoscopic ISR preceded by transanal rectal dissection low rectal cancer. Between December 2009 and June 2011, we performed laparoscopic ISR for 30 patients with very low rectal cancer. Patients received preoperative concurrent chemoradiation (5 days a week for 5 weeks). The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, ISR, transanal coloanal anastomosis with coloplasty and loop ileostomy. Clinical data of 30 patients were analyzed retrospectively. Thirty patients (21 men, nine women) had a median age of 65 years (range, 37 to 75 years), a median body weight of 67 kg (range, 43 to 96 kg), and body mass index of 24 kg/m2 (range, 19 to 33 kg/m2). The distance of the tumor from the anal verge was 5 cm (range, 2 to 11 cm). The operative time was from 240 to 360 minutes, and estimated blood loss was 100 to 520 mL. There were no conversions and no postoperative mortality. This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease while preserving anal function.

Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: A cross-sectional study

BACKGROUND

The aim of this study was to analyze the quality of life (QoL), low anterior resection syndrome (LARS) and fecal incontinence after surgery for mid to low rectal cancer and its relationship with the type of surgical procedure performed.

METHODS

A cross-sectional cohort survey study of 358 patients operated on for mid to low rectal cancer. Patients were included in three groups: abdominoperineal resection (APR), low mechanical colorectal anastomosis (CRA) and hand-sewn coloanal anastomosis (CAA). The QLQ-C30/CR29 questionnaires, LARS and Vaizey scores were used to study QoL and defecatory dysfunction. Multivariable analysis was used to estimate the prognostic effect of the variables on QoL and LARS scores.

RESULTS

62.6% of the patients answered the survey. The global QoL score was similar among APR, CRA and CAA. Patients' body image perception was significantly worse after APR than after CRA or CAA. LARS score was better in CRA group (p = 0.002). A major LARS was observed in 83.3% of the patients who underwent CAA and in 56.6% of the patients who underwent CRA. No relationship between surgical procedures and the global QoL score was observed. Neoadjuvant radiotherapy (p = 0.048) and CAA (p = 0.005) were associated with a major LARS. The Vaizey score was higher for CAA than for CRA (p = 0.036).

CONCLUSIONS

Though CAA group presents worse LARS and higher faecal incontinence scores respect CRA patients, and APR is related with a worse body image, global QoL was similar in the three groups.

Quality of Life After a Low Anterior Resection for Rectal Cancer in Elderly Patients

Purpose

Fecal incontinence is a major concern, and its incidence increases with age. Quality of life may decrease due to fecal incontinence after both sphincter-saving surgery and a rectal resection with a permanent stoma. This study investigated quality of life, with regard to fecal incontinency, in elderly patients after rectal-cancer surgery.

Methods

All patients who underwent elective rectal surgery with anastomosis for rectal cancer between December 2008 and June 2012 at two Dutch hospitals were eligible for inclusion. The Wexner and the fecal incontinence quality of life (FIQoL) scores were collected. Young (<70 years of age) and elderly (≥70 years of age) patients were compared.

Results

Seventy-nine patients were included, of whom 19 were elderly patients (24.1%). All diverting stomas that had been placed (n = 60, 75.9%) had been closed at the time of the study. There were no differences in Wexner or FIQoL scores between the young and the elderly patients. Also, there were no differences between patients without a diverting stoma and patients in whom bowel continuity had been restored. Elderly females had significantly worse scores on the FIQoL subscales of coping/behavior (P = 0.043) and depression/self-perception (P = 0.004) than young females. Elderly females scored worse on coping/behavior (P = 0.010) and depression/self-perception (P = 0.036) than elderly males. Young and elderly males had comparable scores.

Conclusion

Quality of life with regard to fecal incontinency is worse in elderly females after sphincter-preserving surgery for rectal cancer. Patients should be informed of this impact, and a definite stoma may be considered in this patient group.

Laparoscopic Low Anterior Resection and Eversion Technique Combined With a Nondog Ear Anastomosis for Mid- and Distal Rectal Neoplasms: A Preliminary and Feasibility Study

The transanal eversion and prolapsing technique is a well-established procedure, and can ensure an adequate distal margin for patients with low rectal neoplasms. Potential leakage risks, however, are associated with bilateral dog ear formation, which results from traditional double-stapling anastomosis. The authors determined the feasibility of combining these techniques with a commercial stapling set to achieve a nondog ear (end-to-end) anastomosis for patients with mid- and distal rectal neoplasms. Patients with early-stage (c/ycT1-2N0), mid- to distal rectal neoplasms and good anal sphincter function were included in this study. Laparoscopic low anterior resection was performed with a standard total mesorectal excision technique downward to the pelvic floor as low as possible. The bowel was resected proximal to the lesion with an endoscopic linear stapler. An anvil was inserted extracorporeally into the proximal colon via an extended working pore. The distal rectum coupled with the lesion was prolapsed and everted out of the anus. The neoplasm was resected with a sufficient margin above the dentate line under direct sight. A transrectal anastomosis without dog ears was performed intracorporeally to reconstitute the continuity of the bowel. Eleven cases, 6 male and 5 female patients, were included in this study. The mean operative time was 191 (129-292) minutes. The mean blood loss was 110 (30-300) mL. The median distal margin distance from the lower edge of the lesion to the dentate line was 1.5 (0.5-2.5) cm. All the resection margins were negative. Most patients experienced uneventful postoperative recoveries. No patient had anastomotic leak. Most patients had an acceptable stool frequency after loop ileostomy closure. Our preliminary data demonstrated the safety and feasibility of achieving a sound anastomosis without risking potential anastomotic leakage because of dog ear formation.

Role of intraoperative frozen section for assessing distal resection margin after anterior resection

BACKGROUND AND AIMS

The use of neoadjuvant long-course chemoradiotherapy (LCRT), shorter distal safety margins (DSMs) and stapled or intersphincteric resections has increased sphincter preservation rates. While intraoperative frozen section (IOFS) is not mandatory, it helps achieve negative distal resection margins (DRMs). Our aim was to audit the role of IOFS for DRM assessment while performing sphincter-saving rectal surgery and to identify those subgroups that would benefit the most from IOFS analysis.

METHODS

Patients who underwent rectal cancer surgery between 2009 and 2013 were identified from a prospectively maintained database. Patients who intraoperatively underwent an IOFS for DRM assessment were included in the study. Factors associated with a positive margin on IOFS were analysed. The sensitivity and specificity of IOFS were also assessed.

RESULTS

Of 250 patients, who had an anterior resection with an IOFS, 12 had an involved DRM. Of these patients, eight were involved by adenocarcinoma, two by acellular mucin, one by moderate dysplasia and one by adenoma confirmed on paraffin section. Positive margins had a 100 % intervention rate. There were two false negative on IOFS. IOFS had a sensitivity of 85.17 % with a specificity of 100 % and a negative predictive value of 99.16 %. Specimens with a positive IOFS were lower rectal (P < 0.05), poorly differentiated and post LCRT locally advanced tumours.

CONCLUSIONS

IOFS to confirm negative DRM is recommended in lower rectal tumours irrespective of DSM. It can be considered for locally advanced post LCRT poorly differentiated mid rectal tumours and avoided for upper rectal tumours.

Multivariate Analysis of Risk Factors Associated With the Nonreversal Ileostomy Following Sphincter-Preserving Surgery for Rectal Cancer

Purpose

A loop ileostomy is used to protect an anastomosis after anal sphincter-preserving surgery, especially in patients with low rectal cancer, but little information is available concerning risk factors associated with a nonreversal ileostomy. The purpose of this study was to identify risk factors of ileostomy nonreversibility after a sphincter-saving resection for rectal cancer.

Methods

Six hundred seventy-nine (679) patients with rectal cancer who underwent sphincter-preserving surgery between January 2004 and December 2011 were evaluated retrospectively. Of the 679, 135 (19.9%) underwent a defunctioning loop ileostomy of temporary intent, and these patients were divided into two groups, that is, a reversal group (RG, 112 patients) and a nonreversal group (NRG, 23 patients) according to the reversibility of the ileostomy.

Results

In 23 of the 135 rectal cancer patients (17.0%) that underwent a diverting ileostomy, stoma reversal was not possible for the following reasons; stage IV rectal cancer (11, 47.8%), poor tone of the anal sphincter (4, 17.4%), local recurrence (2, 8.7%), anastomotic leakage (1, 4.3%), radiation proctitis (1, 4.3%), and patient refusal (4, 17.4%). The independent risk factors of the nonreversal group were anastomotic leakage or fistula, stage IV cancer, local recurrence, and comorbidity.

Conclusion

Postoperative complications such as anastomotic leakage or fistula, advanced primary disease (stage IV), local recurrence and comorbidity were identified as risk factors of a nonreversal ileostomy. These factors should be considered when drafting prudential guidelines for ileostomy closure.

Predictors of fecal incontinence and related quality of life after a total mesorectal excision with primary anastomosis for patients with rectal cancer

Purpose

After total mesorectal excision (TME) with primary anastomosis for patients with rectal cancer, the quality of life (QoL) may be decreased due to fecal incontinence. This study aimed to identify predictors of fecal incontinence and related QoL.

Methods

Patients who underwent TME with primary anastomosis for rectal cancer between December 2008 and June 2012 completed the fecal incontinence quality of life scale (FIQoL) and Wexner incontinence score. Factors associated with these scores were identified using a linear regression analysis.

Results

A total of 80 patients were included. Multivariate analysis identified a diverting ileostomy (n = 58) as an independent predictor of an unfavorable outcome on the FIQoL subscale coping/behavior (P = 0.041). Ileostomy closure within and after 3 months resulted in median Wexner scores of 5.0 (interquartile range [IQR], 2.5-8.0) and 10.5 (IQR, 6.0-13.8), respectively (P < 0.001). The median FIQoL score was 15.0 (IQR, 13.1-16.0) for stoma closure within 3 months versus 12.0 (IQR, 10.5-13.9) for closure after 3 months (P = 0.001).

Conclusion

A diverting ileostomy is a predictor for an impaired FIQoL after a TME for rectal cancer. Stoma reversal within 3 months showed better outcomes than reversal after 3 months. Patients with a diverting ileostomy should be informed about the impaired QoL, even after stoma closure.

The combined abdominal and perineal approach for dissection of the lower rectum. The development of new indications

AIMS

Dissection of the lower rectum in some low rectal and pararectal pathologies can be technically difficult that it ends up in abandoning the procedure or raising a permanent stoma. The recently described combined abdomino-perineal approach allows completion of rectal dissection from the perineal route and preservation of the anal sphincters. Patients requiring the combined approach are not seen frequently and reports on this new technique are scarce. The purpose of this study is to analyze our results of using the combined abdomino-perineal approach in different benign and malignant low rectal pathologies, and to describe two new indications for the technique.

PATIENTS AND METHODS

This is a retrospective analysis of prospectively collected data of 10 patients (8 males, age range 22-75 years), including 7 cancer patients who required the combined abdomino-perineal approach for completion of their procedures. Previously unreported indications for the technique included iatrogenic rectovaginal fistula and presacral tumor. The study was conducted in a tertiary referral colorectal unit in a university hospital.

RESULTS

The procedure was completed and the sphincters preserved in all patients. All cancer patients had adequate resection with good quality mesorectum. Continence was preserved in 4 patients. Three patients are living with permanent stoma. Anastomotic perineal fistula requiring dismantling the anastomosis and raising a permanent stoma occurred in one patient.

CONCLUSIONS

The combined abdomino-perineal approach is useful to complete rectal resection in a highly selected group of patients with technically difficult low rectal pathologies. The technique is probably safe in cancer patients and new indications are evolving. Expectations for preservation of continence are disappointing.

Outcome of Local Excision Following Preoperative Chemoradiotherapy for Clinically T2 Distal Rectal Cancer: A Multicenter Retrospective Study (KROG 12-06)

PURPOSE

The aim of this study was to examine the clinical implications of a pathologically complete response after neoadjuvant chemoradiotherapy (CRT) followed by local excision for patients with cT2 rectal cancer who refused radical surgery.

MATERIALS AND METHODS

Seventeen patients with cT2 primary rectal cancer within 6 cm from the anal verge who received neoadjuvant CRT and local excision because of patient refusal of radical surgery or poor performance status were included. Two patients had clinical involvement of a regional lymph node. Preoperative radiotherapy was delivered to the whole pelvis at a dose of 44 to 50.4 Gy in 22 to 28 fractions. All patients underwent transanal excision and eight patients (47%) received postoperative chemotherapy.

RESULTS

Ten patients (59%) achieved ypT0. At a median follow-up period of 75 months (range, 22 to 126 months), four (24%) patients developed recurrence (two locoregional and two distant). The 5-year disease-free survival of all patients was 82%, and was higher in patients with ypT0 (90%) than in patients with ypT1-2 (69%, p=0.1643). Decreased disease-free survival was also observed in patients receiving capecitabine compared with 5-fluorouracil (54% vs. 100%, p=0.0298).

CONCLUSION

Local excision could be a feasible alternative to radical surgery in patients with ypT0 after neoadjuvant CRT for cT2 distal rectal cancer without further radical surgery.

Living with the physical and mental consequences of an ostomy: a study among 1-10-year rectal cancer survivors from the population-based PROFILES registry

BACKGROUND

This study examined the physical and mental consequences of an ostomy among 1-10-year rectal cancer survivors.

METHODS

Patients with rectal cancer diagnosed from 2000 to 2009, as registered in the population-based Eindhoven Cancer Registry, received a questionnaire on quality of life (QOL; EORTC QLQ-C30), disease-specific health status (EORTC QLQ-CR38), depression and anxiety (HADS), illness perceptions (Brief Illness Perception Questionnaire), and health care utilization; 76% (n = 1019) responded.

RESULTS

A total of 408 (43%) rectal cancer survivors had an ostomy at survey and they reported a statistically significant and clinically relevant lower physical, role, and social functioning, and global health status/QOL but fewer problems with constipation and diarrhea compared with those without an ostomy. Also, they had a significantly worse body image, more male sexual problems, and fewer gastrointestinal problems although these differences were not clinically relevant. No differences regarding the prevalence of symptoms of anxiety and depression were found. Survivors with an ostomy believed that their illness have significantly more serious consequences, will last longer (clinically relevant), and were more concerned about their illness compared with those without an ostomy. Survivors with an ostomy visited their medical specialist, but not their general practitioner, significantly more often. Also, they more often received additional support after cancer treatment.

CONCLUSIONS

Rectal cancer survivors with an ostomy have a lower QOL, worse illness perceptions, and a higher health care consumption compared with those without an ostomy 1-10 years after diagnosis.

The techniques of sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision in low rectal cancer surgery

OBJECTIVE

To define the techniques used in lower rectal cancer surgery, by transvaginal and transperineal approach; extrasphincteric dissection, proximal segmental sphincteric excision and transsphincteric rectal resection.

MATERIAL AND METHODS

Between 2007 and 2013, 7 patients (4 female, 3 male with lower rectal cancer were operated by sphincter-saving extrasphincteric disection and proksimal sphincteric excision techniques. After completion of the rectosigmoid dissection and total mesorectal excision up to the puborectal muscle level; extrasphincteric rectal dissection, transsphincteric rectal resection and ultra-low coloanal anastomosis were performed by using the transvaginal and transperineal approach in the sublevator phase of the operation.

RESULTS

Seven patients were operated with sublevator access for lower rectal cancer. Bowel contiunity has been provided in all patients. One patient died due to surgical complications in the early postoperative period. One patient deceveloped anastomotic leakage and there were two patients with anastomotic stricture. Circumferential resection margin and tumoral perforation were found negative in all of the patients. Tumoral deposits at the distal resection line was observed in one patient.

CONCLUSION

The techniques of sublevator rectal resection may be considered as an alternative sphincter-saving surgical method, especially in lower rectal cancer surgery.

Coloanal anastomosis or abdominoperineal resection for very low rectal cancer: what will benefit, the surgeon's pride or the patient's quality of life?

PURPOSES

Sphincter-saving operation with coloanal anastomosis (CAA) has become an established option for very low rectal cancer, but few studies have compared its functional results and quality of life (QoL) with abdominoperineal resection (APR) showing controversial results.

PATIENTS AND METHODS

Patients treated for low rectal cancer with APR or CAA, disease-free after a median follow-up period of 26.5 (8-84) and 52.5 (12-156) months, respectively, were retrospectively reviewed. General and disease-specific changes in QoL and severity of disease were evaluated by Karnofsky scale, EORTC-C30, EORTC-CR38, SF-36, PGWBI, FIQL, PAC-QoL, ICIQ-SF, Stoma-QoL, AMS, Wexner's score and obstructed defecation syndrome (ODS) score.

RESULTS

Twenty-six APR patients and 34 CAA patients entered the study. Karnofsky score did not show significant differences. The median Stoma-QoL was 58.2 (45-76.6), indicating a good stoma function in 95% of patients. EORTC-C30, CR38, PGWBI and SF-36 questionnaires did not show significant differences between the two groups except for sexual function (better after CAA, p = 0.01). Eleven patients after APR and eight after CAA had urinary incontinence, and its severity did not differ significantly. Eighteen of 21 CAA patients complained of faecal incontinence [AMS, 80 (15-120); Wexner, 13 (2-19)] with an impact on their QoL [FIQL: lifestyle, 1.75 (0-4); coping/behaviour, 1.3 (0-3.5); depression, 2.1 (0-5.2); embarrassment, 2 (0-4.6)] and 11 complained of obstructed defecation [7.5 (3-16)] with significant consequences on QoL [PAC-QoL, 30.4 (19.2-80.3)].

CONCLUSIONS

QoL in patients with permanent stoma and in those after CAA did not differ significantly. APR patients had worse sexual function, while most CAA patients had faecal incontinence and sometime obstructed defecation, with important impact on their QoL.

Comparison of intracorporeal single-stapled and double-stapled anastomosis in laparoscopic low anterior resection for rectal cancer: a case-control study

PURPOSE

Recently, a single-stapled technique (SST) was performed instead of the conventional double-stapled technique (DST) in laparoscopic low anterior resection for anastomosis, by placement of intracorporeal purse-string sutures on the distal rectum with transanal specimen extraction. This study aimed to compare the short-term outcomes between the two anastomotic techniques.

METHODS

Between July 2007 and April 2010, 60 patients underwent SST by laparoscopic or robotic procedure. These patients were matched 1:2 by age, gender, date of surgery, and tumor stage with 120 patients who underwent conventional DST in laparoscopic low anterior resection.

RESULTS

The robotic-assisted operative approach was used more frequently in the SST group than in the DST group (61.7 % vs. 3.3 %, p < 0.001). The mean operative time was 203.9 (range, 120-400) min for the SST group and 167.6 (range, 90-300) min for the DST group (p < 0.001). For specimen removal, the transanal approach was used in the SST group, while the transabdominal approach was used for the DST group. The pain score (visual analogue scale) of the SST group was lower (4.5 vs. 5.6, p < 0.001), although postoperative recovery was similar. Pathological examination revealed that the distal resection margin was significantly longer in the SST group (3.1 vs. 2.5 cm, p = 0.018). Postoperative morbidity including anastomotic leakage was similar in both groups.

CONCLUSIONS

SST yielded equivalent short-term outcomes when compared to conventional DST and provided the advantages of minimal access and a longer distal resection margin. Therefore, SST in lower anterior resection may be a useful alternative to conventional DST.

Combination of pseudocontinent perineal colostomy and appendicostomy: a new approach in the treatment of low rectal cancer

BACKGROUND

Abdominal perineal resection (APR) with applied colostomy remains the standard treatment for low rectal cancer; however, to date, a very high morbidity rate has been reported.

AIMS

The aims of this study were to assess fecal continence, persistence of disease-related symptoms, and quality of life in patients with low rectal cancer after APR and pseudocontinent perineal colostomy and concomitant appendicostomy.

METHODS

We included 17 patients with low rectal cancer who underwent APR at our hospital in this cross-sectional study. Following APR, pseudocontinent perineal colostomy and concomitant appendicostomy were performed. Patients then underwent antegrade colonic enema with tap water. Patients' symptoms, fecal continence, and quality of life were evaluated at regular time intervals.

RESULTS

After a median follow-up of 12 months, 15 of 17 patients completed the study period. All patients were able to perform an antegrade enema by themselves. Mean continence score was 7 (out of 20) based on the Wexner Scale scoring system. Mean global health status score was 78, physical function was 93, and emotional function was 88. Minor morbidity was observed in 6 patients (40%).

CONCLUSION

Pseudocontinent perineal colostomy with appendicostomy provides an acceptable level of continence and functional and emotional improvement in patients with low rectal cancer undergoing APR. Hence, this combinative method could be considered as an alternative for abdominal colostomy in selected patients.

Systematic review of outcomes after intersphincteric resection for low rectal cancer

BACKGROUND

For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer.

METHODS

A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011.

RESULTS

Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7.

CONCLUSION

Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.

Quality of life after coloanal anastomosis and abdominoperineal resection for distal rectal cancers: sphincter preservation vs quality of life

AIM

A permanent colostomy is considered to have an adverse impact on quality of life (QOL). However, functional outcomes following sphincter preservation also affect QOL. Our aim was to determine differences in QOL of patients undergoing coloanal anastomosis (CAA) or abdominoperineal resection (APR) for distal rectal cancer.

METHOD

Eighty-five patients underwent CAA (72 with intestinal continuity and 13 with a stoma because of complications) and 83 patients underwent APR for a distal rectal cancer between 1995 and 2001 at a single institution and responded to our survey. QOL was evaluated using the EORTC QLQ-C30 and QLQ-CR38.

RESULTS

Patients with CAA were younger than APR patients (mean age 57 vs 62 years, P < 0.001), but gender distribution, tumour stage and proportion of subjects receiving radiotherapy was not significantly different. Patients undergoing CAA had higher scores (better QOL) for physical functioning; lower scores (fewer symptoms) for fatigue, pain, financial difficulties, weight loss and chemotherapy side effects; and higher scores (more symptoms) for constipation and gastrointestinal symptoms compared with APR patients. CAA patients had higher scores (better QOL) for body image in men but not in women. Sexual functioning scores in men and women were lower (worse QOL) in CAA patients compared with APR patients.

CONCLUSIONS

QOL after APR is comparable to sphincter preservation, although there are some differences that need to be considered. QOL and functional results should be taken into account with the oncological outcome when devising management strategy for distal rectal cancer.

Analysis of super-low anterior resection for rectal cancer from a single center

PURPOSE

The purpose of this study was to evaluate the outcome and genitourinary complications of super-low anterior resection (SLAR) followed by adjuvant radiochemotherapy in the management of patients with low rectal cancer.

METHOD

One hundred and six low rectal cancer patients managed with SLAR were analyzed retrospectively.

RESULTS

There were seven patients who failed to follow up, and the 5-year survival rate was 65.7% (65/99). There were 35 patients (35.4%) who developed distant metastases, and 12 (12.1%) had local recurrence. The local recurrence rates were 21.1% (4/19), 7.1% (2/28), 5.9% (1/17), and 0% (0/2) in the patients with tumor distance of less than or equal to 2 cm, ranging from 2.1 to 3.0, from 3.1 to 4.0, from 4.1 to 5.0, and more than 5 cm, respectively. This implied local recurrence rate increased against the distance between the lower margin of tumor and resection line. Ninety-eight of 106 rectal patients had complete data of questionnaire: 58 scored 1, 32 scored 2, 7 scored 3, and 1 score 4. This revealed that the fecal function of most patients (91.8%, 90/98) was normal or nearly normal. Twenty-four of 37 males suffered from sexual dysfunction, and among them, eight were impotent (all older than 70 years), and 29 had retrograde ejaculation. Meanwhile, seven of 35 females suffered from sexual problem, 1 had dyspareunia, seven had decreased lubrication, and one had inability to achieve orgasm.

CONCLUSIONS

SLAR followed by adjuvant radiochemotherapy can effectively control local-regional disease and can be one choice of avoiding the functional morbidity of abdominoperineal resection.

A new sphincter-preserving operation for low rectal cancer: ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method

PURPOSE

The introductions of total mesorectal excision and double-stapling technique into colorectal surgery have promoted the clinical application of sphincter preservation. However, for the tumors localized on the middle or lower level of rectum, sphincter-preservation approaches might be problematic in some patients. We introduce in this report a new sphincter-preserving technique for low rectal cancer.

METHODS

Between August 1999 and May 2004, 310 patients underwent ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method for low rectal cancer localized in the lower third of rectum. Postoperative evaluation included anal function, anastomotic leakage, anastomotic stenosis, cumulative survival rate, and local recurrence.

RESULTS

Three hundred ten patients received the sphincter-preserving operation without severe intraoperative complications. One patient died of lung dysfunction (0.3%). All patients had satisfactory anal function without soiling. The median follow-up was 84 months (9-136 months) and overall survival rate was 97.0% at 1 year, 73.5% at 3 years, and 66% at 5 years. Thirty-six patients (11.6%) patients developed local recurrence. Postoperative complications included anastomotic leakage (1.6%), anastomotic stenosis (2.5%), and local and distant recurrence (11.6% and 18.4%, respectively).

CONCLUSIONS

Ultralow anterior resection and colorectal/coloanal anastomosis by supporting bundling-up method may be one of the best choices of sphincter-preserving operation for low rectal cancer.

Quality of life and local recurrence of posterior pelvic exenteration with anal preservation

AIM: To evaluate the quality of life and local recurrence for rectal cancer which under vent posterior pelvic exenteration (PPE) with anal sphincter preservation.

METHODS: Sixty cases with rectal cancer invading female reproductive system underwent PPE with anal sphincter preservation (SP group) or colon stoma (CS group) respectively. Thirty cases with low anterior resection rectal cancer were selected as control group (LAR group).Wexner scoring systems and vectorial manometry were used to compare the quality of life between the SP group and LAR group, and compare the 2-year local recurrence rate and survival rate between the SP group and CS group.

RESULTS: Three months after surgery, the Wexner score of SP group was higher than that of the LAR group (10.1 vs 6.1, P < 0.05), but there were no significant difference in score 1 year after surgery between two groups (P > 0.05), and the results of vectorial manometry between two groups also showed no significant difference (P > 0.05). The local recurrence rate and survival rate were 20% and 83.3% for SP group, 23.3% and 80% for CS group with no significant difference observed (both P > 0.05).

CONCLUSION: The quality of life after posterior pelvic exenteration with anal sphincter preservation could reach the level of low anterior resection, and the local recurrence rate and survival rate were similar with colon stoma operation.

Surgical outcome of abdominoperineal resection for low rectal cancer in a Nigerian tertiary institution

BACKGROUND

Rectal cancer is a lifestyle-related illness with an increasing incidence in all developing countries in the last decade. Abdominoperineal resection (APR) offers a good oncologic clearance for low rectal cancer. The remaining controversies surrounding APR, as it is performed in a tertiary center in Nigeria, involve defining the role the operation plays in the management of existing rectal problems and determining what outcomes can be expected. The present study was aimed at examining the surgical outcomes of APR for low rectal cancers in a Nigerian tertiary institution.

MATERIALS AND METHODS

This single-institution, retrospective, descriptive study analyzed APR rate, patient sex and age, subsite involvement, the diagnostic process, follow-up, and survival patterns after treatment of low rectal cancers. The study was conducted at Obafemi Awolowo University Teaching Hospital Complex Ile-Ife, Nigeria, between January 1989 and December 2007.

RESULTS

During the 18-year period, 36 patients underwent APR. This accounts for 24.0% of all patients that had low rectal cancer. The age of the patients ranged from 29 years to 74 years (median: 58.9 years). Most of the patients were 60 years of age or older, and the majority were women (55.9%). The median duration of symptoms was 12 months, and all patients sought medical care for bleeding per rectum. Close to 80% of patients had advanced disease at presentation. Postoperatively, 17 patients (50%) had at least one complication and one patient (2.9%) died. Four (11.8%) patients had recurrence of the tumor, and in every case, recurrence occurred within the first year after operation. Operative blood loss (p = 0.006), degree of differentiation of the tumor (p = 0.011), distance from the anal verge (p = 0.033), and operative stage (p = 0.005) were found to significantly affect the outcome of treatment for the patients who underwent APR. The operative stage similarly affected the survival of patients (Mantel Cox = 0.026).

CONCLUSIONS

Despite the advanced disease of our patients, the outcome of management appears to be comparable with results reported from other centers.

Intersphincteric resection with partial removal of external anal sphincter for low rectal cancer

Abdominoperineal resection (APR) remains the standard procedure for rectal cancer located within 0.5 cm from dentate line (DL). In this study, we present a new type of restorative surgery: intersphincteric resection with partial removal of external anal sphincter (EAS) and anorectal reconstruction for-ultra low rectal cancer. Between March 2003 and May 2008 fifty patients (28 males, aged between 39 and 71) were operated on for ultra low rectal cancer uT2-3N0M0 with partial preservation of EAS and total anorectal reconstruction (smooth-muscle neosphincter and colonic pouch). A protective stoma was performed in all cases. Functional outcome and quality of life were recorded at 3, 6, 12, 18, 24 months after stoma closure using Wexner score and FIQL respectively. Anal manometry, vectrum volumetry and myography data were taken as well. Results. Postoperative complications developed in 2 patients, but no secondary surgery was required. Carcinomas were staged as pT2 (n = 14) and pT3 (n = 36). The distal clearance was 2.00.4 (range 1.5-2.8) cm, lateral clearance was 0.80.3 (range 0.2-1.4) cm. After a median follow-up of 24 (range 2-61) months, 2 local recurrences were occurred and salvaged by APR. Contractive activity of saved elements of EAS improved with a course of time and squeezing anal pressure increased as well. Perfect functional outcome was achieved in 25 of 34 patients at 12 months after stoma closure, and all the patients were satisfied with procedure. Good functional results of suggested surgery seems to be an acceptable alternative to APR with permanent stoma in selected patients.

Comparison of immediate surgical outcomes between posterior pelvic exenteration and standard resection for primary rectal cancer: A matched case-control study

AIM: To determine the immediate surgical outcome and recovery of bowel function following posterior pelvic exenteration (PPE) for primary rectal cancer with suspected local invasion to the female internal reproductive organs, in comparison with a case-control series of standard resection for primary rectal cancer.

METHODS: We analyzed 10 consecutive female patients undergoing PPE for the aforementioned indication between December 2003 and May 2006 in a single institution. Data were prospectively collected during hospitalization, including patient demographics, tumor- and operation-related variables and early surgical outcomes. These patients were compared with a group of female patients, matched for age, co-morbidity and location of tumor, who underwent standard resection for primary rectal cancer in the same period (non PPE group).

RESULTS: In the PPE group, pathological reports showed direct invasion of the reproductive organs in 4 cases and an involvement of lymph nodes in 7 cases. A sphincter-saving operation was performed in each case. Operative time was longer (274 min vs 157 min, P < 0.001) and blood loss was greater (769 mL vs 203 mL, P = 0.008) in the PPE group. Time to first bowel movement, time to first defecation, time to resumption of normal diet, and hospital stay were not significantly different between the two groups. Postoperative complication rates were also similar.

CONCLUSION: PPE for rectal cancer was associated with longer operative time and increased blood loss, but did not compromise immediate surgical outcomes and postoperative bowel function compared to standard rectal resection.

Perineal colostomy with appendicostomy as an alternative for an abdominal colostomy: symptoms, functional status, quality of life, and perceived health

PURPOSE

Abdominoperineal rectum resection with perineal colostomy and appendicostomy for antegrade continence enema has been developed as an alternative for abdominal colostomy or total anal reconstruction in patients with low rectal cancer. This present study was designed to compare symptoms, functional status, quality of life, and perceived health after perineal colostomy and appendicostomy with that after abdominal colostomy.

METHODS

Twenty-seven patients, 14 with abdominal colostomy and 13 with perineal colostomy and appendicostomy, were included. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and CR38 were used to investigate functional status and symptoms. Quality of life was measured by using a Linear Analog Scale and the Satisfaction with Life Scale. Self-perceived health was assessed by using a Linear Analog Scale.

RESULTS

Patients with perineal colostomy and appendicostomy were younger and more frequently female. They experienced better physical functioning (93.3 vs. 73.3 P = 0.048), a slightly better role functioning (100 vs. 83.3 not significant), body image (77.8 vs. 66.7 not significant), and sexual functioning (33.3 vs. 0; not significant) than patients with abdominal colostomy. Stoma-related problems were substantial in patients with abdominal colostomy (38.1) and very limited in patients with an appendicostomy (8.7). Fecal loss did not occur one hour or more after antegrade continence enema in 11 patients with perineal colostomy and was limited in the others. Quality of life and self-perceived health were comparably good in both groups.

CONCLUSIONS

Perineal colostomy with appendicostomy for antegrade continence enema is a valid and acceptable alternative for a permanent abdominal colostomy in selected patients, with a comparable functional and quality of life outcome.

A meta-analysis of quality of life for abdominoperineal excision of rectum versus anterior resection for rectal cancer

BACKGROUND

Avoiding a permanent stoma following rectal cancer excision is believed to improve quality of life (QoL), but evidence from comparative studies is contradictory. The aim of this study was to compare QoL following abdominoperineal excision of rectum (APER) with that after anterior resection (AR) in patients with rectal cancer.

METHODS

A literature search was performed to identify studies published between 1966 and 2006 comparing values of QoL following APER and AR. Random-effect meta-analysis was used to combine the data. Sensitivity analyses were performed for larger studies, those of higher quality and those using self-administered QoL questionnaires.

RESULTS

The outcomes for 1,443 patients from 11 studies, of whom 486 (33%) underwent APER, were included. QoL assessments were made at periods of up to 2 years following surgery. There was no significant difference in global health scores between APER and AR. Vitality (WMD -9.82; 95% CI -27.01, -2.04, P = 0.01) and sexual function (WMD -2.73; 95% CI -4.93, -0.64, P = 0.01) were improved in the AR patients. Patients with low AR had improved physical function scores in comparison with APER patients (WMD -4.67; 95% CI -9.10, -0.23; P = 0.004). Cognitive (WMD 3.57; 95% CI 1.41, 5.73; P < 0.001) and emotional function scores (WMD 3.51; 95% CI 1.40, 5.62; P < 0.001) were higher for APER patients.

CONCLUSION

Overall, when comparing APER with AR, we identified no differences in general QoL following the procedures. Individualisation of care for rectal cancer patients is essential, but a policy of avoidance of APER cannot currently be justified on the grounds of QoL alone.

Outcomes of resection for rectal cancer in India: the impact of the double stapling technique

Background

The introduction of circular staplers into colorectal surgery has revolutionized anastomotic techniques stretching the limits of sphincter preservation. Data on the double-stapling technique (DST) has been widely published in the West where the incidence of colorectal cancer is high. However studies using this technique and their results, in the Indian scenario, as well as the rest of Asia, have been few and far between.

Aim

To evaluate the feasibility of the DST in Indian patients with low rectal cancers and assess its impact on anastomotic leak rates, covering colostomy rates, level of resection and morbidity in patients undergoing low anterior resection (LAR).

Methods

A comparative analysis was performed between retrospectively acquired data on 78 patients (mean age 53.2 ± 13.5 years) undergoing LAR with the single-stapling technique (SST) (between January 1999 and December 2001) and prospective data acquired on 138 LARs (mean age 50.3 ± 13.9 years) performed using the DST (between January 2003 – December 2005).

Results

A total of 77 out of 78 patients in the SST group had Astler Coller B and C disease while the number was 132/138 in the DST group. The mean distance of the tumor from anal verge was 7.6 cm (2.5–15 cm) and 8.0 cm (4–15 cm) in the DST and SST groups, respectively. In the DST group, there were 5 (3.6%) anastomotic failures and 62 (45%) covering stomas compared to 7 (8.9%) anastomotic failures and 51 (65.4%) covering stomas in the SST group. The anastomotic leak rate, though objectively lower in the DST group, did not attain statistical significance (p = 0.12). Covering stoma rates were significantly lower in DST group (p = 0.006). There was 1 death in the DST group due to cardiac causes (unrelated to the anastomosis) and no mortality in the SST group. The LAR and abdominoperineal resection (APR) rates were 40% and 60%, respectively, during 1999–2001. In 2005, these rates were 55% and 45%, respectively.

Conclusion

This study, perhaps the first from India, demonstrates the feasibility of the DST in a country where the incidence of colorectal cancer is increasing. Since the age at presentation is at least a decade younger than the Western world, consideration of sphincter preservation assumes greater significance. The observed improvement of surgical outcomes with DST needs further studies to significantly prove these findings in a population where the tumors at presentation are predominantly Astler Coller Stage B and C.

Treatment Disparities in Hispanic Rectal Cancer Patients: A SEER Database Study

Although Hispanics demonstrate a low overall incidence of rectal cancer, mortality rates have not decreased relative to non-Hispanic whites. To determine if this was in part due to racial disparities in care, we compared rates of neoadjuvant therapy and sphincter-preserving surgery between Hispanics and non-Hispanic whites diagnosed with rectal cancer using the Surveillance, Epidemiology, and End Results (SEER) database. The study population was comprised of 2,573 Hispanics (55.4% male) and 28,395 non-Hispanic whites (56.6% male). Rates of neoadjuvant radiation were 13.5 per cent for Hispanics compared with 10.4 per cent for non-Hispanic whites (P < 0.001). In a Cox proportional hazards model adjusting for nodal status, tumor size, and T stage, non-Hispanic whites were significantly less likely to have received neoadjuvant therapy (hazard ratio, 0.72; P < 0.001; 95% confidence interval 0.63–0.83). Rates of sphincter preservation were 67 per cent for Hispanics and 70 per cent for non-Hispanic whites (P = 0.003). Non-Hispanic whites were significantly more likely to have received a sphincter-preserving operation than Hispanics (hazard ratio, 1.076; P = 0.019; 95% confidence interval 1.02–1.27). We conclude that Hispanics are significantly more likely to receive neoadjuvant therapy but are less likely to receive sphincter-sparing operations for rectal cancer compared with non-Hispanic whites. Further studies are required to assess the impact of these treatment disparities on patient outcome.

Abdominoperineal resection or anterior resection for rectal cancer: patient preferences before and after treatment

OBJECTIVE

Literature data do not provide any evidence as to whether oncological outcome and quality of life after anterior resection (AR) are superior to those observed after abdominoperineal resection (APR) for low-lying rectal cancer. In view of this, patient preferences should play an important role in the process of decision making. The aim of this study was to investigate these preferences.

PATIENTS AND METHODS

A series of consecutive patients with rectal cancer (60 prior to surgery, 65 after APR and 124 after AR) who attended our outpatient clinic were asked to express their preference as to the type of surgery. The second part of the study was performed 4 years later; 30 patients evaluated before surgery, free of disease, were again asked to express their preference as to the type of treatment.

RESULTS

Patient preferences as to performing APR, AR or as to leaving the decision to the surgeon were as follows: (i) the group prior to surgery - 5%, 30% and 65%, respectively, (ii) group after APR - 46%, 22% and 32%, respectively, and (iii) group after AR - 4%, 69% and 28%, respectively. Patients after AR pointed to the type of surgery that they had undergone more frequently than patients after APR (69%vs 46%, respectively, P < 0.001). Sixty per cent of patients evaluated twice had altered their initial preferences, usually choosing the type of surgery that they had undergone.

CONCLUSIONS

Our results suggest that the sequelae of AR are generally perceived as more acceptable than those of APR. Nevertheless, approximately half of the patients after APR prefer the type of surgery that they have undergone, which suggests the positive reappraisal of APR, once experienced.

Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials

BACKGROUND AND PURPOSE

According to common conviction rectal tumour shrinkage after preoperative radio(chemo)therapy increases the likelihood of anterior resection (AR). In order to verify this belief, we performed a systematic review of randomised trials.

PATIENTS AND METHODS

We identified 10 randomised trials encompassing altogether 4596 patients in whom preoperative radio(chemo)therapy resulted in tumour shrinkage in the experimental arm as compared to the control arm.

RESULTS

Tumour shrinkage observed in the experimental groups did not result in a statistically significant higher ARs rate in any study when we performed an analysis of all the randomised cases. Subgroups of patients considered to be candidates for abdominoperineal resection before randomisation were identified in three trials. A statistically significantly higher rate of ARs was demonstrated in the experimental arm of the CAO/ARO/AIO 94 study. However, in that study, sphincter preservation was a secondary endpoint and some features of the trial may bias the estimation of the effect. The benefit of sphincter preservation was not confirmed by subgroup analyses performed in the Lyon R90-01 study and in the Polish study, which were originally designed to evaluate the sphincter preservation issue.

CONCLUSION

The body of evidence gathered from randomised trials does not support the concept of a beneficial effect of preoperative radiotherapy on the ARs rate.

Surgical treatment of rectal cancer: radical resection

Currently, surgery is the only potentially curative treatment modality for rectal cancer. The major goals of surgery for rectal cancer are to optimize oncologic outcome and maintain anorectal and genitourinary function. This article reviews the surgical management of primary rectal cancer and discusses major surgical considerations in the treatment of this disease.

The management of rectal cancer in a resource poor environment - a review

Rectal cancer is an increasing problem in the developing world. There is little written on how to manage this problem outside the confines of major teaching hospitals in Western Countries. In these centres debate surrounds preoperative staging, the use of preoperative radiotherapy and sophisticated sphincter preserving procedures. The literature is complex and of little relevance to those faced with a patient with rectal cancer in rural Africa or Asia far from the ivory towers. This review aims to combine the best of evidence based medical practice related to the management of rectal cancer with the practical realities of operating in resource poor environments. In this situation staging is by means of simple radiology and a clinical examination supplemented by an examination under anaesthetic. If there are no distant metastases and the tumour is freely mobile a resection can be attempted. An abdominoperineal resection is a good operation with a proven track record. If an anastomosis can be fashioned then an anterior resection is an excellent operation and should be performed extrafascially to avoid local recurrence. It is vital to counsel the patient preoperatively. The pros and cons of referral to a centre of excellence need to be discussed with the patient prior to any intervention.

Impact of Short-Term Preoperative Radiotherapy on Health-Related Quality of Life and Sexual Functioning in Primary Rectal Cancer: Report of a Multicenter Randomized Trial

Background

Few prospective studies have been performed about the impact of preoperative radiotherapy (PRT) or total mesorectal excision (TME) on health-related quality of life (HRQL) and sexual functioning in patients with resectable rectal cancer. This report describes the HRQL and sexual functioning of 990 patients who underwent TME and were randomly assigned to short-term PRT (5 × 5 Gy).

Patients and Methods

The Rotterdam Symptom Check List supplemented with additional items was used with questionnaires before treatment and at 3, 6, 12, 18, and 24 months after surgery. Patients without a recurrence the first 2 years were analyzed (n = 990).

Results

Few differences were found in HRQL between patients treated with or without PRT. Daily activities were significantly less for PRT patients 3 months postoperatively. Irradiated patients recovered slower from defecation problems than TME-only patients (P = .006). PRT had a negative effect on sexual functioning in males (P = .004) and females (P < .001). Irradiated males had more ejaculation disorders (P = .002), and erectile functioning deteriorated over time (P < .001). PRT had similar effects in patients who underwent a low anterior resection (LAR) versus an abdominoperineal resection (APR). Patients with an APR scored better on the physical (P = .004) and psychologic dimension (P = .007) than LAR patients, but worse on voiding (P = .0007).

Conclusion

Short-term PRT leads to more sexual dysfunction, slower recovery of bowel function, and impaired daily activity postoperatively. However, this does not seriously affect HRQL. The comparison between LAR and APR patients demonstrates that the existence of a permanent stoma is not the only determinant of HRQL.

Increased use of low anterior resection for veterans with rectal cancer

BACKGROUND

Two surgical procedures with curative intent are available to patients with rectal cancer: lower anterior resection and abdominoperineal resection; however, lower anterior resection may improve quality of life and functional status.

AIM

To examine temporal changes in after lower anterior resection and abdominoperineal resection between 1989 and 2000. Potential factors associated with the use of lower anterior resection were evaluated.

METHODS

Using national administrative data, we identified patients who received lower anterior resection or abdominoperineal resection. Logistic regression models examined the association between use of lower anterior resection and time period of surgical resection.

RESULTS

A total of 5201 rectal cancer patients underwent resection. The use of lower anterior resection increased from 40.0% (1989-91) to 50.1% (1998-2000) paralleled by a corresponding decline in abdominoperineal resection (60.1 to 49.9%; P < 0.001). Patients who received surgery during 1992-94, 1995-97 and 1998-2000 were 6, 7 and 28% more likely to receive lower anterior resection, when compared with 1989-1991 after adjusting for demographic characteristics, co-morbidity and hospital surgical volume. Older age, lower co-morbidity score and lower hospital surgical volume were predictive of lower anterior resection.

CONCLUSIONS

An increase in the use of lower anterior resection for rectal cancer was observed over time. This observed increase in use is not confined to high-volume hospitals.

Sphincter-saving surgery for low rectal cancer. The experience of the National Cancer Institute, Milano

The treatment of tumors of the distal rectum continues to be a matter of great controversy among oncologic surgeons. There are increasingly promising indications that functionally conservative surgery may be a valid therapeutic alternative to conventional therapy in patients with tumours of the lower rectum, traditionally treated by abdomino-perineal resection and definitive colostomy. Many points are presently under evaluation and we want to discuss some of the most relevant topics that are now permitting to change the guide lines of therapy of this disease. Our view of the problem is based on a personal experience cumulated in fourteen years of activity in a specialized unit and this paper reports the main results of a complex and diversified study carried out during this period at the National Cancer Institute of Milan.