Ultra-low Anterior Resection Research Articles

A Diverting Stoma Is Not Necessary when Performing a Handsewn Coloanal Anastomosis for Lower Rectal Cancer

Although a temporary diverting stoma is a frequent surgical procedure for the protection of anastomosis in a sphincter-preserving operation for lower rectal cancer, its impact on anastomotic leakage is not conclusive. This study was designed to evaluate anastomotic complications after ultralow anterior resection and handsewn coloanal anastomosis without a diverting stoma for lower rectal cancer patients. Between January 1995 and December 2005, 96 patients were treated by ultralow anterior resection and handsewn coloanal anastomosis for lower rectal cancer. Fifty-one patients received preoperative concurrent chemoradiation, whereas 45 had no preoperative treatment. No diverting stoma was created in any of these cases. The anastomotic complications were evaluated between the groups. Six of 96 patients (6.1 percent) developed anastomotic complications: three anastomotic stenoses, one partial anastomotic dehiscence, one retrorectal abscess, and one rectovaginal fistula. All of the complications occurred in the preoperative radiation group, whereas none from the nonradiation group had an anastomotic complication (P=0.017). The patients with stenosis and partial dehiscence were managed conservatively. The patient with retrorectal abscess was treated with debridement, irrigation and drainage, and seton procedure with a transanal approach. The patient with rectovaginal fistula underwent a second coloanal anastomosis. The anastomotic complication rate was low even without a diverting stoma. This study suggests that a diverting stoma is not necessary when performing a handsewn coloanal anastomosis for lower rectal cancer however, an effort should be made for healthy anastomotic healing in patients with rectal cancer who are preoperatively radiated.

Concurrent laparoscopic right hemicolectomy and ultra-low anterior resection with colonic J-pouch anal anastomosis for synchronous carcinoma

An extensive large bowel resection with a single anastomosis is the accustomed management option for widely spaced synchronous colorectal neoplasms. We report a successful case of concurrent laparoscopic right hemicolectomy and ultra-low anterior resection with colonic J-pouch anal anastomosis in an 85-year-old man with synchronous cancers of the hepatic flexure and lowrectum. This surgical technique is advantageous for elderly patients as it provides the benefits of multiple segmental resection and laparoscopic surgery while potentially reducing mortality, time of procedure, postoperative pain, ileus, length of hospitalization and direct cost of care, and improving independence at discharge. The technique for efficient multiple extractions of specimens and effective reconstitution of pneumoperitoneum for a multistaged procedure is discussed.

Effect of curved cutter stapler in the ultra low anterior resection for low rectal cancer

To evaluate the curative effect of curved cutter stapler (Contour, Ethicon Endo-Surgery, Inc) in the ultra low anterior resection for low rectal cancer. Clinic data of 56 patients with low rectal cancer from Dec. 2005 to Sep. 2006 were reviewed retrospectively. After total mesorectal excision (TME) and lateral lymph node dissection (LLD) in 56 cases, the rectal (anal) remnant was cut and closed with curved cutter stapler (Contour), and preserved for ultra low colo-rectal (anal) anastomoses with 33 mm straight intraluminal stapler. There was no operational death and the mean hospitalization time was (11.2+/-3.2) days. The incidence rate of postoperative complications in 1 month was 3.57% (2/65). Both of the cases were anastomotic leakage. One was cured by surgical drainage, the other combining with rectal vaginal fistula was cured by transverse colostomy. Curved cutter stapler has the advantages of complete cutting, safe closure and low anastomotic leakage rate in the process of ultra low anterior resection for low rectal cancer.

Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery

The aim of this study is to evaluate the influence of dividing the inferior mesenteric artery (IMA) and preserving the left colic artery (LCA) on rectosigmoid cancer surgery. Colonic blood flow at the proximal site of the anastomosis was measured by laser Doppler flowmetry in 96 patients with cancer of the rectum and sigmoid colon while clamping IMA or LCA. Results were analyzed with patient characteristics and postoperative complications. Blood flow was significantly decreased by either IMA or LCA clamping, and its reduction rate was 38.5 +/- 1.8%, ranged from 0 to 82.8%, or 16.4 +/- 1.8%, ranged from 0 to 66.2%, respectively. For multivariate analyses, aging and male gender were predictive factors of high blood flow reduction by IMA clamping. The reduction rate was significantly correlated with aging in male patients, while no such correlation was observed in women. Aging correlation in men was more significant in ultralow anterior resection cases. Three elderly male patients received IMA high ligation among 19 patients who demonstrated more than 50% blood flow reduction by IMA clamping. Among these, two patients, those who underwent ultralow anterior resection, suffered severe anastomotic ischemia. Colonic blood flow at the proximal site of the anastomosis was significantly decreased by either IMA or LCA clamping. Patients with high reduction by IMA clamping need intraoperative efforts to prevent anastomotic ischemia, particularly in elderly male patients who undergo ultralow anterior resection.

Laparoscopic anterior resection and total mesorectal excision for rectal cancer: a prospective nonrandomized study

The purpose of this study was to present our experience of laparoscopic total mesorectal resection, including ultralow resection and coloanal anastomosis. Between 1993 and 2005, patients fit for general anesthesia, with resectable cancers, and with lower edge of tumor beyond 5 cm of the anal verge were subjected to laparoscopic anterior resection with sphincter preservation. Double stapling technique is used to establish bowel continuity. A total of 170 patients, 88 males and 82 females, were subjected to successful laparoscopic anterior resection, which included high anterior resection (n=90), low anterior resection (n=52), ultralow anterior resection (n=20), and coloanal anastomosis (n=8). The average age of patients was 58.4 years (12-90 years). Mean operating time was 130 min and mean hospital stay was 7 days. The morbidity was 13.5% with nil mortality. With an average follow-up of 49 months (range 9 years to 3 months), 9 patients developed local recurrence and 45 patients developed distant metastasis. In selected cases, laparoscopic anterior resection is possible for all levels of rectal tumors, allowing sphincter preservation and maintaining oncological safety.

The incidence of anastomotic leaks in patients undergoing colorectal surgery

There is evolving interest in auditing and credentialling the performance of surgeons. The incidence of anastomotic leakage has been proposed as a measure of performance following colorectal surgery. The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage in patients undergoing resections of the colon and rectum. A prospective database was developed for all patients undergoing colorectal surgery. Anastomotic leakage was defined prior to the commencement of the study. A logistic regression analysis was performed to determine independent predictors of leakage. The variables analysed included age, sex, American Society of Anesthesiology (ASA) score, anatomical location, pathology, emergency surgery, type of anastomosis, a covering stoma and radiotherapy. Significance was defined as the probability of a type 1 error of < 5%. The results are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs). There were 1598 patients who underwent 1639 anastomoses. Their mean age was 63 years, 34% of patients were ASA 3 or 4, and 16% of the operations were emergencies. Anastomotic leaks occurred in 2.4% (40/1639) of anastomoses. The leak rate for intraperitoneal anastomoses was 1.5% (19/1283) vs 6.6% for extraperitoneal anastomoses (21/316). Half of these leaks (20/40) were managed with re-operation or percutaneous drainage procedures. Ultra-low anterior resections were associated with the highest leak rate (8%, 18/225). A logistic regression analysis identified a covering stoma (P = 0.0001, OR 5.078, 95% CI 2.527-10.23) and diverticular disease (P = 0.037, OR 2.304, 95% CI 1.053-5.042) as independent predictors of a leak. Within this surgical unit, the incidence of leaks from intraabdominal anastomoses was relatively low. However, leaks in patients undergoing extraperitoneal anastomoses continue to be a major cause of morbidity and mortality.

A Defunctioning Ileostomy Does Not Prevent Clinical Anastomotic Leak After a Low Anterior Resection: A Prospective, Comparative Study

Defunctioning ileostomy or colostomy is still routinely performed after low anterior resection in the belief that diverting the fecal stream will prevent anastomotic dehiscence. However, an ileostomy is not without morbidity for the patient. This study aims to determine if a diverting stoma is really necessary after a low anastomosis. All low or ultralow anterior resections done in this department were performed by consultant-grade surgeons in a standardized manner. The patients were all monitored closely after surgery for clinical signs of an anastomotic leak. There were 1078 patients who underwent elective low or ultralow anterior resections in a ten-year period between 1994 and 2004. Twelve of them were irradiated before surgery; they were excluded from the study. During a seven-month period from February 2004 through August 2004, 324 patients who underwent such procedures were not defunctioned. These were compared with 742 patients who were previously defunctioned with a proximal stoma. The results were analyzed using the Pearson chi-squared test. Thirteen (4 percent) patients who were not defunctioned developed a clinical anastomotic leak, whereas the leak rate for those who were defunctioned was 3.8 percent. There was no statistical difference demonstrated. Ninety-five percent of patients who developed a leak required surgical intervention; the remaining 5 percent could be dealt with by radiologic drainage. The overall mortality rate for anastomotic leak in this department is 7.3 percent. A diverting stoma does not reduce postoperative anastomotic leak rate. Rather, it reduces the otherwise catastrophic effects of an anastomotic leak such as fecal peritonitis and septicemia. An ileostomy carries certain morbidity and also adds to the cost of the entire operation. Therefore, it should not be performed routinely. Instead, it should be performed selectively in patients with poorly prepared bowels, coupled with a distal limb washout, and in patients with significant comorbidities who can ill afford the complications of a leak.

Hand-Sewn Coloanal Anastomosis for Distal Rectal Cancer: Long-Term Clinical Outcomes

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n = 1), and anal stenosis (n = 7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.

Clinical utility of a de‐functioning loop ileostomy

The de-functioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the faecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. The value of de-functioning stomas is currently being challenged. The purpose of the present study was to review the clinical utility of performing a de-functioning loop ileostomy in patients undergoing colorectal surgery. A review was undertaken of a prospective colorectal database maintained at Fremantle Hospital. All end-points were defined prior to the collection of data. The study reviewed the indications and type of surgery performed. The main end-points included (i) the prevalence and management of anastomotic leaks at the primary surgery; (ii) unplanned readmissions prior to stoma closure; and (iii) the mortality, reoperation rate, and morbidity associated with closure of the stoma. The study involved 233 patients of mean age 58 years (range 15-89 years) and a male:female ratio of 1.1:1. The majority of patients were undergoing elective surgery (82%) for colorectal neoplasia (71%). The commonest surgical procedure was an ultra-low anterior resection (62%). At the initial surgery, 16 patients (7.0%) developed anastomotic leaks, but only two (0.9%) required reoperation. Eleven patients (4.8%) required 12 unplanned readmissions prior to stoma closure. At closure (n = 230), there were no postoperative deaths, one patient developed an ileal anastomotic leak that was managed with antibiotics, and five patients (2.2%) required reoperation within 30 days of surgery. De-functioning loop ileostomy was found to be associated with a relatively low morbidity and no mortality.

Denervation of the Neorectum as a Potential Cause of Defecatory Disorder Following Low Anterior Resection for Rectal Cancer

The aim of this study was to determine whether denervation of the sigmoid colon during low anterior resection contributes to the postoperative motility characteristics of the neorectum and to the defecatory function of patients. Sixty-seven patients who underwent either low or ultralow anterior resection for rectal cancer were evaluated. In accordance with the length of denervated neorectum, each patient was assigned to either the short-denervation or long-denervation group, determined by whether the inferior mesenteric artery was divided. Colonic propagated contraction was then measured by means of intraluminal pressure monitoring. Transit time was calculated with orally administered radiopaque markers. Propagated contraction down to the neorectum was significantly less common in the long-denervation group (14/36) than in the short group (12/15, P < 0.05), whereas spastic minor contraction at the neorectum was significantly more common in the long-denervation group (21/36) than the in short group (3/15, P < 0.05). Colonic transit time below the sigmoid colon was significantly longer in long group (6.4 hours) than in the short group (3.4 hours, P < 0.01). Although motility disorder of the neorectum was correlated with clinical defecatory malfunctions, including multiple evacuations, urgency, and soiling, no significant correlation was noted between the length of the denervated neorectum and the defecatory disorders. Motility of the neorectum following low anterior resection appears degraded by intraoperative maneuvers that cause denervation of the remnant sigmoid colon. Motility disorder of the neorectum, but not the length of the denervated neorectum causing the disorder, correlates well with several defecatory malfunctions. This finding suggests that postoperative defecatory disorder as a result of low anterior resection is caused by many factors in addition to denervation of the neorectum.

Changes in outcome with sphincter preserving surgery for rectal cancer in Korea, 1991–2000

To report the clinical and oncological data of patients operated on for rectal cancers 3-5 cm from the AV over a 10 year period, including the Sphincter preservation (SP) rate. We reviewed medical records of 304 patients with rectal cancers 3-5 cm from the AV who underwent surgical resection from January 1991 through December 2000. The 10 years were divided into three periods based on the introduction of new surgical techniques, specifically, ultralow anterior resection (ULAR) with double stapling in March 1994 and ULAR with coloanal anastomosis in April 1997. The rates of SP, complications and patient survival during these periods were compared. The SP rate increased significantly over the 10 years, from 16.4% in period I (January 1991-February 1994), to 53.0% in period II (March 1994-March 1997), to 86.5% in period III (April 1997-December 2000) (p<0.001). Over time, the age of the patients increased (p=0.004), the length of the distal resection margin became shorter (p=0.005), and the rate of lymph node metastasis increased (p=0.016). The factors significantly influencing SP were the period (p<0.001) and the distance from the AV (p<0.001). Over time, morbidity did not increase, and overall and disease free survival rates did not decrease. In contrast, the overall survival of N2 cases significantly increased over time (p=0.0492). Over 10 years, the SP rate in rectal cancers 3-5 cm from the AV was significantly increased by the introduction of the double stapling and coloanal anastomosis techniques. These surgical methods, however, had no effect on morbidity, disease free survival and overall survival rates.

Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer

There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA) in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA. Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire (Fecal Incontinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales). We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown. Furthermore, we found that FISI scores highly correlated with FIQL scales. This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE for low-lying rectal cancer.

Local recurrence following surgical treatment for carcinoma of the lower rectum.

The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).

Minilaparotomy left iliac fossa skin crease incision vs. midline incision for left-sided colorectal cancer.

Midline laparotomies offer excellent exposure but are associated with increased postoperative pain and longer recovery. A minilaparotomy resection of leftsided colorectal cancers was studied as an alternative approach. We performed a case-control retrospective review of 280 randomly selected patients (140 midline incisions; 140 left skin crease incisions) who underwent elective, curative resection of left-sided colorectal cancers. Patients in both groups were of comparable age and sex. The left skin crease incision was shorter (median length, 13.5 cm) than the midline incision (median length, 20.0 cm). Median operation time was less in the left skin crease group (75 min) than in the midline incision group (105 min). Similar types of operations were performed, including left hemicolectomies, sigmoid colectomies, anterior resections and ultra-low anterior resections. Adequacy of resection was confirmed by histological analysis, with no involvement of margins. The median numbers of lymph nodes removed were comparable: 10 for the skin crease incision group and 12 for the midline incision group. Postoperative parameters for the skin crease incision group showed that feeding, ambulation, narcotic use and hospital stay were significantly better than the parameters in the midline group. Complications of intestinal obstruction were also reduced in the skin crease incision group. The limited left skin crease incision provides adequate margins of clearance in colorectal cancers when compared to the midline incision, but has advantages of shorter operation time, earlier feeding and ambulation, and earlier discharge from hospital.

Large contractions in the colonic J-pouch as a possible cause of incomplete evacuation

Restoration of neo-rectal capacity is of importance in obtaining better bowel function after low anterior resection for rectal carcinoma. However, evacuatory disorders, such as incomplete evacuation, have been reported in some patients undergoing colonic J-pouch reconstruction. Therefore, we conducted this study to explore the possible factor affecting incomplete evacuation following low anterior resection for rectal carcinoma. The subjects were 37 consecutive patients who had undergone low anterior resection for rectal tumor (colonic J-pouch in 13 patients, straight anastomosis in 24). Clinical and physiological outcomes were determined at a mean follow-up time of 12 months after the operation, and the parameters were compared between patients with and without postoperative incomplete evacuation. Although anastomosis level from the anal verge was lower in the J-pouch group (6.5 cm vs 3.9 cm, P<0.05), there was no significant difference between J-pouch and straight reconstruction regarding clinical and physiological outcomes. Postoperative incomplete evacuation was significantly more frequent in the J-pouch group than in the straight group (46% vs 25%, P<0.05). Postoperative large contractions on ano-rectal manometry were also significantly more apparent in the J-pouch group than in the straight group (31% vs 4%, P<0.05). Presence of postoperative large contractions (P=0.004), anastomotic stricture (P=0.019) and smaller postoperative maximum tolerable volume ( P=0.009) were significantly and independently associated with incomplete evacuation by multivariate analysis. Colonic J-pouch reconstruction following ultra-low anterior resection was comparable with higher level straight anastomosis from the clinical and physiological point of view. The presence of large contractions might be an important indicator of incomplete evacuation in patients who are undergoing rectal resection.

Ultralow anterior resection with intersphincteric dissection--what is the limit of safe sphincter preservation?

In the treatment of low rectal cancer, the possibility of sphincter preserving surgery is increased by partial sphincteric resection which may allow an oncologically safe resection margin in some patients who would traditionally have been treated by abdominoperineal resection. The aim of this study is to evaluate the morbidity, mortality and the oncological and functional results of intersphincteric resection to determine whether the technique may be considered a safe means of sphincter preservation. Between May 1992 and December 1999, 26 patients (mean age 55 years, range 28-82) with adenocarcinoma of the rectum had partial sphincteric resection by an abdominal approach with a colonic J-pouch anal anastomosis. The mean distance between the tumour and the anal verge 4.25 (range 3.1-5.25) cm. Four tumours were T1, 14 T2 (3 N+), 7 T3 (3 N+), and 1 T4 (N+). Neoadjuvant radiotherapy was used in 10 patients. The distal resection margin was positive in one patient who then proceeded to safe abdominoperineal resection (APR). In the remaining patient the mean distal resection margin on the fixed specimen was 1.6 (range 0.3-3.5) cm. There were no deaths. Morbidity was 30% with an anastomotic leak rate of 11%. At mean follow-up of 39 (range 11-93) months the local recurrence rate was 3.4%. Functional results were evaluated in 25 patients at mean follow-up of 27 (8-66) months: 65% had 0-2 bowel motions per 24 h, 31% had 3-5 and 4% between 6 and 9. Nine patients (36%) had nocturnal defecation. Continence was normal in 50% with 23% reporting incontinence to gas and 27% reporting minor episodes of incontinence. None had major incontinence and 85% considered their outcome satisfactory. This study supports the current literature indicating that partial sphincteric resection is an oncologically and functionally safe alternative to abdominoperineal resection for some selected low rectal tumours.

Physiological and functional outcome following ultra-low anterior resection with colon pouch-anal anastomosis.

Low rectal cancer is usually managed by ultra-low anterior resection (ULAR) with total mesorectal excision and straight coloanal anastomosis. However, following this procedure patients often suffer from frequency, urgency of bowel action and, occasionally, faecal incontinence. To overcome such problems, a colon pouch may be fashioned and a subsequent colon pouch-anal anastomosis performed. The physiological and functional outcome following the use of a colon pouch are appraised. All relevant papers identified from a Medline search and papers from cross-referencing were reviewed. Creation of a colon pouch following ULAR results in reduced bowel frequency, and a lower incidence of urgency and faecal incontinence. Although there is a slightly increased incidence of evacuatory disorder and need for enemas or suppositories, this appears to be a minor problem which may possibly be overcome by using a smaller colon pouch. Compared with straight coloanal anastomosis following ULAR, the creation of a colon pouch produced a superior functional outcome.

Primary Rectal Lymphoma as a Cause of Bowel Obstruction Report of a Case

Malignant lymphoma involving the rectum either as a localized process or as a manifestation of disseminated disease is rare. Several treatments have been proposed and reported, including surgical resection alone or associated with adjuvant chemoradiation, chemotherapy alone, and radiotherapy alone. A case of bowel obstruction caused by a primary rectal MALT lymphoma is reported. Following emergency loop sigmoid colostomy the patient was started on multiple specific cycles of chemotherapy according to the MACOP-B protocol. At the end of chemotherapy a remarkable reduction in the size of the tumor was noted. Subsequently the patient underwent an ultralow anterior resection followed by a straight coloanal anastomosis. At 36 months of follow-up the patient is alive with no tumor recurrence. The present report describes the unique case of a patient with primary obstructing rectal lymphoma treated with neoadjuvant chemotherapy and sphincter-saving curative surgery.

Ultralow anterior resection and coloanal anastomosis for distal rectal cancer: functional and oncological results.

We evaluated the functional and oncological outcome of ultralow anterior resection and coloanal anastomosis (CAA), which is a popular technique for preserving anal sphincter in patients with distal rectal cancer. Forty-eight patients were followed up for 6-100 months regarding fecal or gas incontinence, frequency of bowel movement, and local or systemic recurrence. The main operative techniques were total mesorectal excision with autonomic nerve preservation; the type of anastomosis was straight CAA, performed by the perianal hand sewn method in 38 cases and by the double-stapled method in 10. Postoperative complications included transient urinary retention (n=7), anastomotic stenosis (n=3), anastomotic leakage (n=3), rectovaginal fistula (n=2), and cancer positive margin (n=1; patient refused reoperation). Overall there were recurrences in seven patients (14.5%): one local and one systemic recurrence in stage B2; and one local, two systemic, and two combined local and systemic in C2. The mean frequency of bowel movements was 6.1 per day after 3 months, 4.4 after 1 year, and 3.1 after 2 years. The Kirwan grade for fecal incontinence was 2.7 after 3 months, 1.8 after 1 year, and 1.5 after 2 years. With careful selection of patients and good operative technique, CAA can be performed safely in distal rectal cancer. Normal continence and acceptable frequency of bowel movements can be obtained within 1 year after operation without compromising the rate of local recurrence.

Local recurrence after curative anterior resection with principally blunt dissection for carcinoma of the rectum and rectosigmoid.

The aim of this study was to determine the incidence of local pelvic recurrence of carcinoma of the rectum and rectosigmoid (tumors where the lower edge is 18 cm or less from the anal verge) in a consecutive series of patients operated on by a single surgeon. All patients underwent curative anterior resection and a formal anatomic dissection of the rectum where mobilization was achieved through a principally careful blunt manual technique along fascial planes, preserving an oncologic package. During the period April 1986 to December 1997, 157 consecutive anterior resections for carcinoma of the rectum and rectosigmoid were performed by one surgeon (ALP). One hundred thirty-eight (87.9 percent) were curative, and 19 (12.1 percent) were palliative. The mean follow-up period was 46 +/- 31.6 (range, 2-140) months. Data were retrospectively collated and computer coded by an independent contracted medical research team. Follow-up data were available on all patients. Four (3.1 percent) of the 131 patients undergoing curative anterior resection had local recurrence. Local recurrences occurred between 16 and 38 months from the time of resection, and the cumulative risk of developing local recurrence at five years was 5.2 percent. All tumors in which pelvic recurrence occurred were high grade, and the probability of developing local recurrence at five years for this group was 13.9 percent, which is significantly higher compared with patients who had average or low-grade tumors (P = 0.01). The probability of developing local recurrence at five years for Stage I tumors was 0, Stage II was 5.9 percent, and Stage III was 8.9 percent. In addition, there was a significantly higher incidence of local recurrence in the group of patients undergoing ultralow anterior resection (between 3 and 6 cm from the anal verge) as compared with patients undergoing low or high anterior resection (P = 0.03). Local recurrence developed in 3 of 28 (10.7 percent) patients having ultralow anterior resection, 1 of 57 (1.8 percent) patients having low anterior resection (between 6 and 10 cm from the anal verge), and no patients having high anterior resection (above 10 cm from the anal verge). The clinical anastomotic leak rate for curative anterior resection was 7 of 131 patients (5.3 percent). Thirty-seven of the 131 (28.2 percent) required a proximal defunctioning stoma; 35 (41.2 percent) of these were established for low or ultralow anterior resections and 2 for high anterior resection. The overall five-year cancer-specific survival rate of the entire group of 131 patients was 81.8 percent, and the overall probability of being disease free at five years including both local and distal recurrence was 72.9 percent. Three local recurrences occurred in the 101 patients (77 percent) who did not receive any form of adjuvant therapy. One local recurrence occurred in the 18 patients (13.7 percent) who had adjuvant chemoradiation. No recurrence occurred in the 12 patients (9.2 percent) who had adjuvant chemotherapy alone. Curative anterior resection for carcinoma of the rectum and rectosigmoid with principally blunt dissection of the rectum in this study is associated with a 3.1 percent incidence and a 5.2 percent probability at five years of developing local recurrence. Evidence from this study indicates that, as with sharp pelvic dissection, a low incidence and probability of local recurrence can be achieved by a principally blunt mobilization technique through careful attention to preservation of fascial planes in the pelvis and removal of an oncologic package with selective rather than routine adjuvant or neoadjuvant chemoradiation.