Abdominosacral resection for midrectal cancer. A fifteen-year experience

Prone en bloc sacrectomy with proctectomy: a surgical approach to the inaccessible and hostile pelvis

AIM

Reoperative pelvic surgery is rarely hostile and unsafe. Kraske's procedure has historically been used to approach the mid-rectum and to resect retrorectal tumors. However, it provides limited access to the pelvis and is best in the 'virgin' pelvis. We have encountered a select group of patients who required completion proctectomy or resection of a disconnected ileoanal J-pouch where trans-abdominal access to the pelvis was not possible and access to the pelvis could only be safely gained by a prone en bloc sacrectomy.

METHOD

We describe a prone approach that provides an alternative route of access to the hostile pelvis. After exposure of the sacrum and coccyx and transection of the sacrum, access to the mesorectal plane is achieved and a proctectomy (or resection of an ileoanal J-pouch) can be completed. The procedure is similar to the Kraske approach but requires a higher and wider exposure similar to the extent of an abdominal resection; however, the operation is performed in 'reverse'.

RESULTS

We found that this approach was feasible and safe in the previously operated, hostile pelvis. We employed it in one patient to excise a disconnected J-pouch with chronic sepsis and in another patient for a completion proctectomy. Both patients had an uneventful recovery and clear margins were obtained with no complications.

CONCLUSION

The en bloc prone sacrectomy approach is a useful alternative in a very select group of patients with difficult trans-abdominal access to the pelvis. Experience in pelvic surgery and identification of clear anatomical landmarks is paramount to avoid catastrophic uncontrollable bleeding.

Place of Abdominoperineal Excision in Rectal Cancer

In an attempt to elucidate if and when there is a place for abdominoperineal excision in rectal cancer, we have evaluated survival, risk of local recurrence and functional results of alternative procedures. There seems to be no difference in survival rate after intended curative surgery for rectal cancer between rectal excision and sphincter-saving resection. This is also true with respect to risk of local recurrence, except in patients with poorly differentiated Dukes’ C tumours, where the risk of significant distal intramural spread is increased.

Functional results are satisfactory after low anterior resection with colorectal anastomosis, whereas coloanal anastomosis is followed by less satisfactory results especially in elderly patients. In these patients rectal excision with a permanent colostomy is probably preferable.

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.

Abdominosacral amputation of the rectum for low rectal cancers: ten years of experience

BACKGROUND

Abdominoperineal resection for rectal cancer is related to the high frequency of local recurrences, risk of inadvertent bowel perforation, and disease-positive tumor margin. An alternative technique to this procedure, however, is the abdominosacral amputation of the rectum (ASAR). The aim of this study was to report on the technique and share our experience of ASAR on the cohort of consecutively operated patients.

METHODS

In its anterior stage, ASAR follows the rules of total mesorectal excision. In its posterior part, the patient is positioned in a prone jackknife position and the coccyx and the last sacral vertebra (if necessary) are removed, enabling a sharp and directly visualized resection of the tumor and other structures critical to local recurrence. Between 1998 and 2007, a total of 210 low-rectal cancer patients were so treated at our clinic.

RESULTS

Bowel perforation occurred in 9 patients, the circumferential resection margin was positive in 16 patients, and 38 patients had local wound complications. Seven (4.4%) of 158 patients with 2-year follow-up developed local recurrence, whereas 5-year observed and relative survivals were 68.3% and 73.2%, respectively.

CONCLUSIONS

ASAR has a low risk of bowel perforation, circumferential resection margin involvement, and local wound complications. The local recurrence rate is lower and survival better than with conventional abdominoperineal resection.

Abdominosacral resection is not related to the risk of neurological complications in patients with low-rectal cancer

OBJECTIVE

Some authors claim that the risk of sacrectomy-related neurological complications is a serious limitation of abdominosacral resection (ASR). We determined the incidence of neurological complications in patients with a low-rectal cancer who were treated by ASR.

METHOD

The clinical records of 54 consecutive patients with low-rectal cancer who were operated on by ASR were analysed. The occurrence of neurological complications in these patients was compared with that of 140 consecutive patients with cancer of the mid- and upper rectum who underwent anterior resection (AR) during the same period. Neurological complications were defined as bowel, bladder or sexual dysfunction, gait abnormalities and local parasthesiae persisting for more than 6 months following surgery.

RESULTS

There were no persisting neurological complications after either AR or ASR. At the end of hospitalization, the 16 of 140 and 12 of 54 of those treated with AR and ASR had neurological complications, which fell to five of 140 and three of 53 at 3 months, respectively; at 6 months, no one treated had any complications.

CONCLUSION

Neurological complications after AR and ASR were similar but recovery was complete at 6 months following surgery.

Therapeutic results in low-rectal cancer patients treated with abdominosacral resection are similar to those obtained by means of anterior resection in mid- and upper-rectal cancer cases

AIMS

To present the experiences of the Regional Comprehensive Cancer Center in Wroclaw with abdominosacral resection (ASR) carried out in low-rectal cancer patients.

METHODS

Rectal cancer patients (n=294) were operated on by the same surgical team using the standardized TME technique between May 5, 1998 and February 23, 2001. Depending on the distance from the anal verge, the primary tumor was removed by means of standard abdominal resection (AR-mid- and upper-rectal cancers) or abdominosacral resection (ASR-low-rectal cancers). The patients who underwent the different operative procedures were comparable in terms of distributions of age, gender, tumor infiltration depth and regional lymph node involvement with no significant statistical difference between the groups.

RESULTS

Ninety-seven cases were excluded from the analysis of survival based on exclusion criteria defined. Consequently, 197 cases were left for further analysis, including 154 patients operated on by AR and 43 who underwent ASR. AR and ASR patients did not differ significantly in terms of postoperative morbidity (11% and 14%, respectively), observed (57.1% vs. 60.4%) and relative 5-year survivals (74.3% vs. 73.2%) and the cumulative 5-year local recurrence rate (5.8% vs. 4.7%).

CONCLUSION

The combined use of the modern TME technique and the "historical" abdominosacral excision of the rectum seems to give new, potentially attractive perspectives for successful surgical treatment of low-rectal cancers.

Novel use of a threadwire saw for high sacral amputation

✓ The authors describe and demonstrate an innovative modification of the osteotomy procedure required to achieve a supraforaminal high sacral amputation in a patient harboring a large sacral chordoma. Via a combined anterior—posterior approach, three carefully placed threadwire saws were used to create releasing osteotomies through specific portions of the dorsal iliac crests and through the axial midportion of the S-1 vertebral body. The threadwire saws are pulled away from neurovascular and visceral structures, ensuring greater protection. Other advantages include markedly reduced blood loss while performing the osteotomies, a high degree of cutting accuracy, negligible bone loss, and ease and speed of bone cutting.

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.

Complications are Increased with the Need for an Abdominal-Assisted Kraske Procedure

The Kraske procedure offers a sphincter-saving alternative for surgical correction of rectal disease. This study was performed to investigate the complication rate with the traditional (transsacral) Kraske procedure versus an abdominal-assisted Kraske approach (laparoscopic or open). We conducted a retrospective review of all patients undergoing the Kraske procedure at Harper University Hospital over a 10-year period. A total of 54 patients were identified. Indications for surgery included rectal carcinoma (43), large villous adenomas (6), and other (5). Average postoperative follow-up was 40 ± 25 months (mean ± SD). Complications included rectocutaneous fistulae (9), perineal infections (13), and incontinence (8). In patients requiring an abdominal-assisted approach for colorectal mobilization, the fistula rate was significantly higher (33% vs 3%; P = 0.007), as were the rates of perineal infections (33% vs 17%) and of initial incontinence (25% vs 7%). The laparoscopic-assisted approach significantly reduced the operating time (272 ± 72 minutes) compared to the open-assisted approach (498 ± 138 minutes) ( P < 0.001). The traditional Kraske procedure can be utilized in a safe, effective manner for treatment of rectal disease. Knowledge of the increased rate of complications with the abdominal-assisted Kraske approach can guide the patient and physician considering sphincter salvage.

Local excision of rectal tumors

Local excision is increasingly being used to treat rectal cancer. It appears to be an attractive option because of low morbidity and excellent functional results. Controversies remain regarding available techniques, selection criteria and results with or without adjuvant therapy. Role of salvage therapy remains uncertain. This review examines available evidence in an attempt to clarify the role of local excision in the management of rectal cancer.

Role of local excision in the treatment of rectal cancer

Local excision (LE) of properly selected rectal cancers can provide long-term survival, with minimal morbidity, negligible mortality, and excellent functional results. The role of LE has evolved over the past century. Initially, to avoid the excessive mortality of abdominal surgery, aggressive LE was performed to control the symptoms of rectal cancer. As abdominal surgery became safer, LE was restricted for use in palliation or high-risk patients. Better preoperative tumor staging resulted in an expanded role for LE, including curative-intent treatment of selected T(1-2) rectal cancers. Techniques for LE include snare polypectomy, transanal excision, transanal endoscopic microsurgery, and posterior approaches. The high local recurrence rate and compromised survival reported in modern series, despite efforts to properly select patients with cancers suitable for LE, have convinced the authors to restrict the use of curative-intent LE in good-risk patients only to the most favorable rectal cancers. Close follow-up after LE is critical, because radical surgical salvage is usually possible if recurrence is identified promptly. Whether adjuvant chemoradiation can expand the role of curative intent LE remains controversial.

Transanal endoscopic microsurgery

The anatomy of the pelvis makes it difficult to perform local excisions in the rectum when a tumour is some distance from the anal verge. Transanal endoscopic microsurgery, a minimally invasive procedure, has been developed. It provides an alternative to the transsacral or transabdominal approach, with subsequent shorter hospital stay and fewer complications.

Posterior sagittal approach: megasigmoid resection and anal reconstruction for severe constipation and fecal incontinence after anoplasty

PURPOSE

The aim of this study was to present the technique of megasigmoid resection and anal reconstruction by complete posterior sagittal approach for the children with severe constipation and fecal incontinence after anoplasty.

METHODS

Six patients (age, 2 to 18 years) born with imperforate anus and originally treated with perineal anoplasty suffered from intractable constipation and fecal incontinence. Contrast enema showed massive dilated and aperistaltic rectosigmoid colon with fecal impaction. Resection of the dilated bowel and anal reconstruction were completely performed by posterior sagittal approach.

RESULTS

The mean operating time was 205 minutes (range, 125 to 265 minutes) and the average length of resected colon was 23.3 cm (range, 10 to 40 cm). There were no intraoperative or postoperative complications. By 2 to 4 months after the operation, all patients obtained voluntary bowel movement. On follow-up at 6 to 24 months postoperative, no patient had constipation or required use of the laxatives again. Four of 6 patients suffered from grade 1 soiling, and the other 2 had grade greater than 1 soiling. None had urinary retention or incontinence after the procedure.

CONCLUSION

Resection of dilated rectosigmoid colon and anal reconstruction for the patients with severe constipation and fecal incontinence after anoplasty can be performed successfully using a posterior sagittal approach.

Total rectal resection, mesorectum excision, and coloendoanal anastomosis: a therapeutic option for the treatment of low rectal cancer

BACKGROUND

There is recent and sporadic evidence indicating that patients with very low rectal cancer may be treated via a sphincter-saving procedure, obviating the need for abdominoperineal resection and definitive colostomy. This study confirms these findings.

METHODS

From March 1990 to October 1994, 79 patients affected with primary low rectal cancers were submitted for total rectal resection, mesorectum excision, and coloendoanal anastomosis. All lesions were located within 8 cm of the anal verge (within 6 cm in 64 cases).

RESULTS

Eight patients relapsed at the pelvic level, and one patient only at the paraanastomotic site. Postoperative morbidity attributable to the procedure was low. A perfect continence was documented in 66% of cases after colostomy closure, and many patients (63%) had one or two bowel movements a day. Sixty-two patients of this series are alive, 49 without actual evidence of disease. Follow-up ranged from 2 to 56 months (median 23).

CONCLUSIONS

The clinical and pathological data derived from this study suggest that radical mesorectum excision more than a large clearance margin of resection remains the most important factor in reducing the incidence of local relapse after low rectal cancer surgery and that total rectal resection and coloendoanal anastomosis is a suitable and safe option to traditional, demolitive surgical techniques.

Is transanal endoscopic microsurgery (TEM) a valid treatment for rectal tumors?

BACKGROUND

In 1983 G. Buess, in Germany, developed transanal endoscopic microsurgery (TEM), a new minimally invasive technique for the treatment of rectal tumors.

METHODS

Rectal lesions are excised through a modified rectoscope of 40 mm in diameter under stereoscopic control in the gas-dilated rectal cavity. Full-thickness excision, partial-wall excision, or mucosectomy can be performed. Seventy-one patients were treated with the TEM technique in our department. Major complications were observed in one patient (1.4%). No mortality was reported.

RESULTS

Histological examination revealed 40 (56.3%) villous adenomas, 6 (8.4%) pT1; 17 (23.9%) pT2; 5 (7%) pT3 carcinomas; and 3 ((4.2%) other lesions. The recurrence rate was 2.8% for adenomas and 2.8% for carcinomas. The overall survival at mean follow-up of 17 months was 96.4%.

CONCLUSIONS

The advantages of TEM are less or no postoperative pain, unrestricted mobility, short hospitalization, quick rehabilitation, and absence of skin scars.

Middle and lower third rectum carcinoma: sphincter saving or abdominoperineal resection?

Sphincter saving resections (SSR) are performed with increasing frequency in carcinoma of the lower and middle third of the rectum. In this retrospective study local and distant recurrence and survival were compared to abdominoperineal resection (APR). In 71 women and 71 men (mean age: 64 years) with a primary adenocarcinoma between 5 and 10 cm from the anal verge 89 SSR, and 53 APR, were performed (Dukes stages--SSR--A 19%; B 30.3%; C 50.7% vs APR--A 15%; B 45.3%; C 39.6%). Patients have been followed up for a minimum of 24 months (mean time 62 months). There were no differences in intraluminal diameters of the tumours in each operative procedure. The distal tumour-free distance was more than 6 cm in 52% after APR (SSR: 10%) and less than 3 cm in 43% after SSR. Survival was not different between procedures in Dukes stages A and B. A survival advantage for patients with Dukes C carcinoma after APR did not reach statistical significance. No differences in distant spread were found for SSR (Dukes stage A 0%; B 7%; C 18%) and APR (Dukes stage A 0%; B 8%; C 14%) for local recurrence in Dukes stages A and B after SSR (A and B 0%) and APR (A 0%; B 8%) whereas a significant increase in local recurrence rate was seen in Dukes stage C after SSR (24% vs, APR 5%). Although a further resection could be performed in almost all of these patients a negative effect of local recurrence on survival occurred (25.4 months with and 80 months without local recurrence). While SSR seems to be favourable in Dukes stages A and B, APR should be considered in carcinoma of the lower and middle third of the rectum with lymphatic spread. Effective preoperative staging determines selection of the appropriate operation.

Immediate vs. salvage resection after local treatment for early rectal cancer

PURPOSE

There is an increasing awareness of local procedures to treat early stage rectal cancer. Abdominoperineal resection (APR) or low anterior resection (LAR) has been recommended if adverse pathologic findings are encountered in the local excision specimen. No data compare the impact on survival of "immediate" resection for adverse features vs. "salvage" resection for clinical recurrence.

METHODS

We reviewed retrospectively 155 patients who underwent initial curative treatment of invasive rectal cancer by excision (91), snare-cautery (44), and fulguration (20).

RESULTS

Twenty-one patients underwent APR/LAR immediately after initial local treatment, whereas another 21 patients underwent salvage APR/LAR for local recurrence. The disease-free survival after APR/LAR was 94.1 percent for the immediate group and 55.5 percent for the delayed group (P < 0.05).

CONCLUSION

This decreased survival observed after delayed resection supports the recommendation for immediate APR/LAR when adverse pathologic features are present in the excision specimen.

Analysis of local recurrence rates after surgery alone for rectal cancer

Local recurrence (LR) continues to be a major problem following surgical treatment for rectal cancer, and proposed ways of reducing this remain controversial. The aim of this study was to review results from published surgical series in which adjuvant therapies were not used. A Medline search identified series published between January 1982 and December 1992 with follow-up on at least 50 patients with rectal cancer treated surgically for cure, without adjuvant therapy. Fifty one papers reported follow-up on 10,465 patients with a median LR rate of 18.5%. LR was 8.5%, 16.3% and 28.6% in Dukes' A, B and C patients respectively, 16.2% following anterior resection and 19.3% following abdominoperineal resection. Nine papers (1,176 patients) reported LR rates of 10% or less. LR was 7.1% in 1,033 patients having total mesorectal excision and 12.4% in 476 patients having extended pelvic lymphadenectomy. Routine cytocidal stump washout in 1,364 patients was associated with 12.2% LR, however a higher proportion (41%) also underwent total mesorectal excision. In 52% of cases, LR was reported to have occurred with no evidence of disseminated disease. Surgical technique is an important determinant of LR risk. LR rates of 10% or less can be achieved with surgery alone in expert hands.

Carcinoma of the rectum. Profiles of intraoperative and early postoperative complications

PURPOSE

The aim of this study was to determine the incidence and risk factors that were significant in contributing the intraoperative and early postoperative complications for operations of carcinoma of the rectum.

METHODS

Between 1984 and 1986 inclusive, 426 patients underwent surgery for primary adenocarcinoma of the rectum. Cases of local excision were excluded. The relationship between each complication and nominal risk factors were studied. The types of surgery included an abdominoperineal resection, low anterior resection, low anterior resection with coloanal anastomosis, anterior resection, colostomy, and Hartmann's procedure.

RESULTS

There were two (0.5 percent) deaths. Intraoperative complications occurred in 34 (8 percent) patients. The most common intraoperative complication was presacral bleeding which occurred in 14 patients. Postoperative complications occurred in 214 (50 percent) patients. The two most common complications were urinary retention and urinary tract infection. Abdominoperineal resection had the highest early postoperative complication rate (59 percent). There were 17 clinical anastomotic leaks (7 percent in 221 patients with unprotected anastomoses). The development of complications reached statistical significance with increasing age (P = 0.003), male sex (P = 0.003), increasing weight (P = 0.006), and types of operative procedure (P = 0.001).

CONCLUSIONS

Operations for carcinoma of the rectum can be performed with low mortality. Although the overall early postoperative complications were high, the majority was not life-threatening and usually resolved with time and proper management.

New perspective in the treatment of low rectal cancer: total rectal resection and coloendoanal anastomosis

PURPOSE

Presently abdominoperineal resection still remains the most diffuse modality of treatment of low rectal cancer. However, a new surgical approach is now available to avoid such a demolitive surgery and a definitive colostomy.

METHODS

From March 1990 to March 1993, 58 total rectal resections were performed in 55 patients affected with primary or recurring cancers of the low rectum. As a restorative procedure, a colic J-shaped pouch and a handsewn pouch-endoanal anastomosis was adopted. All of the primary lesions were within 7 cm of the anal verge; in 74 percent the distal tumor margin was located less than 6 cm from the cutaneous edge.

RESULTS

Histologic clearance of the rectum cut edge was documented in all cases. Seven patients relapsed locally from 7 to 14 months after surgery and in 3 more cases distant metastases were documented. Postoperative morbidity is low. After colostomy closure in 78 percent of patients, perfect continence was achieved and in 74 percent less than two bowel movements a day were recorded. Fifty patients are presently alive, 46 without evidence of disease. The follow-up ranged from 2 to 37 (median, 13) months.

CONCLUSION

This experience, along with data obtained from last year's literature, indicates that a conservative surgical procedure, such as total rectal resection and coloendoanal anastomosis, can be considered a feasible and radical option for treatment of low rectal cancer.

Radical abdominopelvic lymphadenectomy: historic perspective and current role in the surgical management of rectal cancer

Radical abdominopelvic lymphadenectomy for rectal cancer is based on the tenet that removal of all potentially involved lymphatic tissue will yield a lower rate of locoregional failure and improve survival. At centers with extensive experience with the procedure, the operating time is only modestly prolonged compared with conventional resection. Blood loss and postoperative hospitalization are not significantly increased. Urinary dysfunction and impotence associated with radical abdominopelvic lymphadenectomy (as high as 80 percent and 76 percent, respectively, in recent series) have been major deterrents to its more routine application. Preservation of the hypogastric plexus and even selective preservation of a unilateral S4 nerve root have been shown to reduce the occurrence of genitourinary complications. Improved five-year survival of 68 percent and local recurrence rates of 5 to 20 percent for TNM Stage III cancers have been achieved with radical abdominopelvic lymphadenectomy. These results compare favorably with recent trials of adjuvant chemoradiation after conventional resection in stage-matched patients. The rationale, evolution, and application of radical abdominopelvic lymphadenectomy to the surgical management of rectal cancer are critically examined. The potential benefits of radical abdominopelvic lymphadenectomy, which have been demonstrated in nonrandomized trials, should be evaluated in a prospective and properly randomized study to clearly establish or refute its efficacy.

Recent advances in surgery for colon and rectal cancer

Surgery is the mainstay of therapy for colon and rectal cancer. Over the past several decades, there have been important advances both in the understanding of the biology of colon and rectal cancer and in the preoperative and operative techniques for treating this disease. Although it appears in some studies that we have made a difference in the survival rates in the treatment of colon and rectal cancer, in actual fact, this phenomenon may only be secondary to better staging and, therefore, a greater ability to prognosticate a particular patient's chance of cure. What has been learned in the past 20 to 30 years is that most colon and rectal carcinomas start as polyps of the colon and rectum. Most often, polyps are sporadic, but there are certain high-risk groups that produce polyps and, consequently, colon and rectal cancer at a much higher rate. The goal of a practicing physician is to identify these high-risk individuals and to recommend frequent screenings so as to intervene before a polyp has had a chance to become a deeply invasive cancer. These high-risk groups are best typified by familial adenomatous polyposis, which if left untreated will, in 100% of cases, lead to the death of a patient from colon or rectal cancer. Other diseases that lead to an increase in colon and rectal cancer but may not go through the usual adenoma-to-carcinoma sequence include inflammatory bowel disease such as Crohn's colitis and ulcerative colitis. Most patients with colorectal carcinoma are asymptomatic at the time of diagnosis. This phenomenon has led to efforts to screen the general population for polyps and for cancer. Screening techniques such as the detection of occult blood in the stool and endoscopic procedures are currently the most popular. It is unclear at this time exactly what the efficacy of these techniques is in improving the survival of the general population from colorectal carcinoma. The surgical techniques to remove colon and rectal carcinomas have recently expanded to include a more aggressive local excision policy for small tumors of the rectum and the application of laparoscopic techniques, new stapling techniques, and new anastomosing techniques for tumors of the colon and rectum. These techniques have become possible in part through advances in surgical instrumentation and also in part from our increasing understanding of the biology of the disease. Both have allowed for more creative approaches to diagnosing and treating colon and rectal cancer.(ABSTRACT TRUNCATED AT 400 WORDS)

Conservative treatment of rectal cancer. Extending the indications

Rectal cancer often in the past was believed to require abdominoperineal resection with permanent colostomy to achieve a cure. Several surgical alternatives to colostomy currently are available for selected patients. Understanding of the methods of preoperative staging is increasing, and new techniques, such as intrarectal ultrasound, have provided improved accuracy. By applying this and other methods of preoperative staging, selection of a surgical approach appropriate to the tumor stage increasingly is possible. Curative treatment for rectal cancer often can be achieved while preserving anorectal function.

Electrocoagulation for adenocarcinoma of the low rectum

Cancers of the distal rectum (less than 7.5 cm from the anal verge) that are freely mobile, moderately well or well differentiated, less than 4 cm in size, limited to the bowel wall, and without evidence of metastasis should be considered candidates for treatment with electrocoagulation for cure. Tumor cell ploidy and evaluation with intrarectal ultrasound may in the future add additional useful information with regard to patient selection. Electrocoagulation and laser ablation of tumors may also be useful modalities for palliation of patients with metastatic disease or who are not candidates for curative surgery.

Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum

The results of rectal excision with colonic pouch-anal anastomosis are reviewed from a series of 162 patients covering 7 years. All patients have been operated upon in the same institution and consecutively. The follow-up is now sufficient to allow an accurate evaluation of the outcome of the patients. The main goal of this study was to provide a detailed report of the functional results. Continence was satisfactory in 96% of the patients, with either a perfect continence or minor troubles that would not have been detectable other than by a rigorous questioning. The mean number of bowel movements was 2 per 24 hours. Fragmentation of the defecation and urgency were absent. Twenty-five per cent of the patients had to elicit the evacuation of the reservoir with a suppository or an enema. Improvement of function yielded by a reservoir over straight colo-anal and low colo-rectal anastomoses are significant and, as suggested by manometric studies, are directly related to the restoration of a reservoir function.

Role of pre-operative irradiation for anal preservation in cancer of the low rectum

Since 1979, 157 patients with T2, T3, or T4 cancer of the lower rectum have been treated by a short course of irradiation, 30 Gy within 12 days by cobalt 60 using 120 degrees arc rotation on a sacral field, followed by a 2-month rest before surgery. The operative specimens were tumor-free in 13% of patients, Dukes' A in 40% of patients, Dukes' B in 22% of patients, and Dukes' C in 25% of patients. Three (1.9%) patients died postoperatively. At 3 years (107 patients) and 5 years (74 patients) the rates of death of local failure were 7.5% and 9.5%, respectively. The 3-year and 5-year disease-free survival were 71% and 58%. Since 1983, the surgeons took advantage of the tumor regression to carry out sphincter-saving operation in 67 patients with T2, T3, and T4 tumors of the lower third of the rectum. The proportion of patients treated by restorative surgery instead of abdominoperineal resection has grown significantly during the past 4 years, from 22% to 71%. Diverting colostomy was performed in 10 patients. Anastomotic leakages were observed in 7 patients. Of 31 patients who underwent low anterior resection and were followed 3 to 7 years (mean 4.5 years), 5 patients died of distant metastasis and 3 patients are alive after segmental hepatectomy. One patient had local recurrence which was controlled by abdominoperineal resection. The rate of 3-year disease-free survival was 77%.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary therapy of carcinoma of the large bowel

Most colonic and rectal carcinomas are treated by excision, usually with the object of cure. Adequate and safe resection depends upon sound understanding of the anatomy and pathology of the tumor. The surgical options in various clinical situations are discussed but the final choice has to be individualized. Improved understanding of the biology of large bowel cancer and the advent of circular stapling devices have significantly altered the surgical practice in large bowel cancer. Despite these innovative advances, there has only been a modest improvement in survival over the last few decades. This is because the concept of "sequential tumor spread" does not always hold true. Systemic adjuvant therapy that is effective and safe is needed for selected patients. Notwithstanding, surgical resection remains the most effective therapy for large bowel cancer.

Proctectomy and coloanal reconstruction for rectal cancer

There is increasing interest in the use of coloanal reconstruction following proctectomy for low rectal cancer. The authors review the surgical options for such sphincter-saving approaches, and report their pilot experience with eight patients receiving high-dose preoperative radiation with subsequent proctectomy and endoanal anastomosis. There were no anastomotic leaks.

Local excision for selected colorectal carcinomas

In summary, local excision is a useful tool in the management of selected colorectal carcinomas. The advent of the fibreoptic colonoscope has revised the concept of local excision when dealing with carcinoma-containing polyps of the colon. The clinician now has the means of locally excising certain carcinomas which would have required laparotomy in the not so distant past. In dealing with carcinoma of the rectum, local excision is not advocated for all rectal carcinomas. In fact, when the previously discussed tumour related factors are considered, local excision should be the ultimate procedure in less than 5% of operations performed for rectal carcinomas. However, when appropriately used, local excision provides a less morbid alternative to more radical procedures without compromising patient survival rates or local recurrence rates.

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.

A 5- to 21-year follow-up and analysis of 250 patients with rectal adenocarcinoma

A total of 250 patients with rectal adenocarcinoma were operated on at the University of Chicago Medical Center between 1965 and 1981. The operation performed was curative resection in 154 patients, palliative resection in 16 patients, diverting colostomy in 21 patients, exploratory laparotomy in 11 patients, and transanal removal in 48 patients. Of the 154 curative resections, 115 were abdomino-perineal (APR), three were total proctocolectomies, and 36 were low anterior resections (LAR). No anastomotic complications were observed in this latter group. Operative mortality was 3%. Complete follow-up was obtained in 152 patients (98.7%). Five- and 10-year actuarial survival rates were 68.8 and 59.4%, respectively, for patients with Dukes' B1 adenocarcinoma (n = 32), 55.8 and 44.2% for Dukes' B2 tumors (n = 52), and 42.9% and 25.4% for Dukes' C tumors (n = 63). Distant metastases developed in 59 patients (39.6%), and pelvic recurrence developed in another 18 patients (12%); 5-year survival rates were 23.6% and 22.2%, respectively. Multivariate analysis with Cox regression showed that stage (p = 0.0001), race (p = 0.03), tumor morphology (p = 0.02), and vascular and/or lymphatic microinvasion (p = 0.001) were statistically significant in their association with survival. Logistic regression analysis confirmed these results and allowed for the estimation of 5-year survival probabilities in 16 groups of patients defined by various associations of these four factors. These estimates ranged from a high of 92% in Caucasian patients with Stage B, exophytic tumors with no vascular or lymphatic microinvasion, to a low of 14% in black patients with Stage C, nonexophytic tumors and with the presence of vascular and/or lymphatic microinvasion. Univariate analysis showed that histologic type (p = 0.0006), stage (p = 0.05) and vascular and/or lymphatic microinvasion (p less than 0.001) were significantly associated with the incidence of pelvic recurrence. Analysis of the extent of the operation revealed that the incidence of pelvic recurrence was reduced by the performance of a wide pelvic lymphadenectomy (9.4% vs. 16.4%), but the result did not reach statistical significance (p = 0.16). In conclusion, this study confirms the well-established prognostic value of the Dukes' staging classification of rectal carcinoma. Further, the analysis reveals that race, tumor morphology, and the presence or absence of lymphatic and/or vascular microinvasion significantly influence outcome. By associating these four statistically significant and independent variables, the prognosis for any individual patient can be estimated more precisely than by using Dukes' staging alone.(ABSTRACT TRUNCATED AT 400 WORDS)

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.

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.

Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum

Rectal resection with colo-anal anastomosis was performed in 65 patients with carcinoma of the lower rectum. In 20 a pelvic colonic reservoir was constructed while in 45 a direct anastomosis was carried out. There were no postoperative deaths and morbidity was comparable in the two groups. Functional results were determined by clinical examination and manometry. The frequency of bowel movements was inversely related to the maximum tolerated volume (P less than 0.001). During the first year 60 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two stools per day (P less than 0.05). After one year, 86 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two bowel movements per day (P less than 0.01). The maximum tolerated volume was increased by the reservoir (P less than 0.05). The loss of reservoir capacity of the rectum increases frequency of bowel movements in colo-anal anastomosis. The creation of a colonic reservoir improves function by increasing the maximum tolerated volume without any increase in mortality or morbidity.

Current issues in the treatment of colorectal cancer

For colorectal cancers that are confined to the bowel wall with uninvolved nodes, surgery alone is curative in most patients, and adjuvant treatment is usually not indicated. A combined modality approach for the initial treatment of many rectal and selected colonic carcinomas is based on data that "radical" operations do not necessarily prevent either local regrowth or distant failures and acceptance of a significant palliative but infrequent curative role for irradiation and chemotherapy when such failures occur. Published data for rectal cancer indicates that local recurrence can be markedly reduced by moderate to high dose pre- and post-operative irradiation +/- chemotherapy. For colon cancer, data from pilot trials suggest that post-operative irradiation may reduce local recurrence by stage when compared with surgery alone analyses, but randomized trials are needed. With locally advanced disease, aggressive treatment combinations appear to increase both local control and survival, but much interaction is required between involved physicians.