Ultra-low Anterior Resection Research Articles

Selective total mesorectal excision for rectal cancer

Total mesorectal excision has been advocated for rectal cancer, but its use in upper rectal and rectosigmoid tumors remains a point of debate. One hundred seventeen patients with rectal cancers were subjected to a prospective policy of total mesorectal excision for mid and low rectal cancers and a wide (5 cm) distal margin mesorectal excision for upper rectal and rectosigmoid cancers. Forty-one patients underwent ultralow anterior resection, 10 underwent abdominoperineal excision, 64 had anterior resection and 2 had Hartmann's procedure. The median follow-up was 39 months. Forty-three patients had a defunctioning ileostomy. Three patients (7.3 percent) had anastomotic leaks after ultralow anterior resection with total mesorectal excision. Ninety-three patients had palliative resections. There were four locoregional recurrences in this group, giving an actuarial locoregional recurrence rate of 9.3 percent at five years. The actuarial locoregional recurrence rate after anterior resection was 6.5 percent at five years. The actuarial five-year cancer-specific survival rate was 81.4 percent at five years. These results demonstrate that a policy of wide excision of the mesorectum for upper rectal and rectosigmoid cancer and total mesorectal excision for mid and low rectal cancer is associated with a low locoregional recurrence rate and may be as efficacious as routine total mesorectal excision for all rectal cancers.

Defunctioning loop ileostomy: a prospective audit

Background: Defunctioning loop ileostomies are uncommonly used forms of fecal diversion. The aim of this study was to determine the morbidity associated with both construction and reversal of loop ileostomies. Study Design: An analysis was performed of all patients who underwent loop ileostomy construction or reversal between 1990 and 1997, with data being collected prospectively. Results: One-hundred-two patients, (43 male, 59 female) with a mean age of 38 years (range 13 to 81 years) had loop ileostomies constructed. Indications for ileostomy construction included inflammatory bowel disease (76 patients), ultralow anterior resection for carcinoma (16 patients), or miscellaneous reasons (10 patients). Nine patients (9%) had complications arising from ileostomy construction including 4 parastomal infections, 3 high output ileostomies, 1 small-bowel obstruction, and 1 ileostomy stenosis in the early postoperative period. Only the stricture required surgical intervention. All other complications improved with conservative management. Mean time to ileostomy reversal was 120 days. Three patients (4%) had complications associated with reversal. All of these complications required surgical intervention, 2 for small bowel obstruction, and 1 for small bowel perforation. Currently 84 patients have had their ileostomy reversed, and 12 patients have had their loop ileostomy converted to a permanent stoma for reasons not related to the loop ileostomy itself. Conclusions: Defunctioning loop ileostomy is associated with low morbidity. We recommend a defunctioning ileostomy as the procedure of choice for temporary fecal diversion.

Chemoradiation for rectal cancer: current methods.

The options available for the surgeon treating patients with rectal cancer have multiplied over the last decade, allowing varied approaches to the disease for individual patients. The development of effective adjuvant therapy in the form of radiotherapy and chemotherapy has led to exciting results-and yet more questions to be answered. The decision to employ adjuvant therapy has led to the development of better staging modalities to improve patient selection for the various treatment protocols. The basic issue of timing of therapy-preoperative vs. postoperative-remains hotly contested, and good, prospective, randomized trials are needed before the questions can be answered. The utility of preoperative multimodality therapy in the downstaging of tumors to make curative resection or sphincter preservation possible must be examined. Advances in surgical therapy have been significant, and groups have reported excellent results with total mesorectal excision (TME) in patients without the addition of adjuvant therapy. Other important surgical issues include ultralow anterior resections with colo-anal or J-pouch anal anastomosis, and the efficacy of sphincter preservation through local excision of invasive rectal cancers with or without adjuvant therapy. Each of these issues needs further study and will have great impact on the treatment of rectal cancer as further experience is gained.

Ultra-low anterior resection and coloanal pouch reconstruction for carcinoma of the distal rectum.

Facilitated by an enhanced appreciation for pelvic anatomy and physiology along with a better understanding of patterns of rectal cancer spread, great advances have been made in our ability to perform restorative resections for an ever-increasing proportion of mid and distal rectal cancers. Whereas oncologic results following a low anterior resection were the principal concern 20 years ago, recent efforts have focused on improving functional results as well. Aspirations for improved function need to be tempered by the realization that improved sphincter-saving rates must follow improved oncologic results rather than jeopardize them. Some crucial questions are addressed in this paper: What are the variables involved in optimizing the oncologic and functional results of a low anterior resection and a coloanal reconstruction? What are the issues involved in selecting a particular coloanal reconstruction (straight versus pouch, stapled versus handsewn, with or without fecal diversion) for a particular patient? Who is not a good candidate for a coloanal reconstruction?

Surgical Sphincter Preservation in Rectal Cancer

Improved understanding of the biological features and advances in diagnostic and surgical procedures have been the basis for increased applications of sphincter preserving operations in lower rectal tumors. The relevant treatment strategies along with their indications will be presented and analyzed. New operative procedures comprise transanal excision of early rectal cancer or trans-sphincteric resection or ultralow anterior resection with colon-pouch creation to improve continence. Recently, for cases in which the removal of the rectal sphincter is indispensable for oncological reasons, a continent perineal colostomy has been developed. Reconstruction of the sphinter function is achieved using a seromuscular cuff. This procedure avoids an abdominal colostomy. The neosphincter can also be formed secondarily, after a prior abdomino-perineal excison with transabdominal colostomy.

Advances for Sphincter Preservation in the Surgical Therapy of Rectal Cancer

Improved understanding of the biological features and advances in diagnostic and surgical procedures have been the basis for increased applications of sphincter-preserving operations in lower rectal tumors. The relevant treatment strategies along with their indications will be presented and analyzed. New operative procedures comprise transanal excision of early rectal cancer or trans-sphincteric resection or ultralow anterior resection with colon-pouch creation to improve continence. Recently, for cases in which the removal of the rectal sphincter is indispensible for oncological reasons, a continent perineal colostomy has been developed. Reconstruction of the sphincter function is achieved using a seromuscular cuff. This procedure avoids an abdominal colostomy. The neosphincter can also be formed secondarily, after a prior abdominoperineal excision with a transabdominal colostomy.