Rectal excision with coloanal anastomosis for superficial distal third rectal cancer: survival and local recurrence

OBJECTIVE

Appropriate surgical treatment of distal third rectal cancer limited to bowel wall (i.e. T1 or T2) in medically operable patients is controversial. Transanal excision can deprive some patients of accurate pathological staging, prognosis and cure. In contrast abdominoperineal resection has considerable practical and psychosocial problems largely related to a permanent colostomy. We hypothesize that superficial distal rectal tumours can be effectively treated with rectal excision and coloanal anastomosis.

SUBJECTS AND METHODS

Prospective oncological study of 80 patients with distal third superficial rectal carcinomas treated by complete rectal excision with coloananl anastomosis from December 1977 to January 1993 was carried out. The resected specimens were examined for depth of spread and number of histologically positive nodes. The actuarial local recurrence and survival rates for superficial node-negative and node-positive tumours were analysed independently.

RESULTS

Seventy-eight patients had complete postoperative assessment. Thirty-one percent had received low-dose preoperative neo-adjuvant radiotherapy (3500 rads). Mean follow-up time in all patients was 70 months on average. The lymph node involvement rate for T1 and T2 tumours was 12.5 and 15.6%, respectively. The local recurrence rates for patients with (T1/T2) N0 and (T1/T2) N1 were 1.5 and 16.7%, respectively, and the five year actuarial survival rates were 96.6 and 90%, respectively. The overall local recurrence was 3.8% with five-year actuarial survival of 95.8%.

CONCLUSIONS

Lymph node involvement in superficial tumours is not rare. Rectal excision with coloanal anastomosis results in a high cure rate especially for node-positive superficial tumours. This treatment strategy avoids the psychological trauma of colostomy following abdominoperineal resection and the potential risk of undertreatment by local excision.

[Rectal prolapse]

Rectal prolapse and rectal intussuception correspond to two stages of the same disease. Rectal prolapse is unusual but requires surgical treatment. Abdominal rectopexy is the most effective procedure but increases the risk of postoperative constipation. This risk decreases when the lateral sides are not touched during rectal dissection. The Delorme procedure is associated with a higher rate of recurrence and must be reserved for patients presenting a high risk of postoperative complications. Rectal intussuception is more frequent and is pathological only when arising in the anal sphincter. Rectal intussuception may lead to solitary rectal ulcer and has in this case to be treated by rectopexy. Rectal intussuception involvement in terminal constipation is not yet proved. Internal mucosectomy seems to be the best treatment for terminal constipation.

[Surgery of rectal cancer: total exeresis of the mesorectum]

The authors review the recent literature about total mesorectal excision for rectal cancer. They report the actual management of such patients.

Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses

BACKGROUND

The aim of the study was to assess the influence of partial excision of the superior portion of the anal canal (AC) when necessary for tumor margin clearance in distal rectal cancer on fecal continence after coloanal anastomoses.

METHODS

Between 1977 to 1993, 209 patients with middle and lower third rectal cancers underwent complete rectal excision and coloanal anastomoses. For very low tumors, located at or below 5 cm from the anal verge (AV), varying portions of the superior segment of the AC were excised for tumor margin clearance. The magnitude of resections was inversely proportional to the height of the anastomosis from the AV. The patients were categorized into 3 groups according to their level of anastomoses from AV: group 1, patients with anastomoses from 0.5 to less than 2 cm from AV (1 to 2.5 cm of AC resected, i.e., major resection); group 2, anastomoses at 2 to less than 3 cm from AV (less than 1 cm of AC resected, i.e., minor resection); group 3, with anastomoses at 3 to 3.5 cm from AV (AC completely preserved). A standard questionnaire, physical examination, and anal manometry at intervals of 3, 6, 12, 24, 36, and 48 months were performed prospectively to assess anal continence.

RESULTS

The patients in the 3 categories were matched for age, gender, stage, presence or absence of a colonic J-pouch, preoperative neoadjuvant radiotherapy and surgical technique. Fourteen patients with postoperative radiotherapy were excluded from the clinical assessment. Mean follow-up was 33.5 months. There were 43 patients in group 1, 75 in group 2, and 73 in group 3 for clinical assessment. In the first year, there was progressive improvement in anal continence in all 3 groups. At 2 years, 50% in group 1, 73% in group 2, and 62% in group 3 were fully continent. The proportion of patients fully continent in group 1 remained unchanged as compared to continued improvement for groups 2 and 3 following the first year. At 4 years, 50% in group 1, 80% in group 2, and 68% in group 3 were completely continent. The difference among the 3 groups was not statistically significant.

CONCLUSIONS

For distal rectal cancer, where tumor margin clearance necessitates partial resection of the superior portion of the AC, when limited to less than 1 cm, the proportion of patients remaining fully continent is similar to those with complete AC preservation. More substantial excisions of the AC can still result in satisfactory anal continence, such that following the fourth year, one half of the patients can expect to be fully continent.

[Kock's pouch: experience and clinical course in 31 patients]

OBJECTIVES

To analyse the morbidity and functional results of Kock's continent urinary diversion performed since 1992 in cystectomized patients in whom the urethra could not be used.

MATERIAL AND METHODS

From March 1992 to June 1998, 31 Kock's pouches were performed by 2 surgeons on a group of patients with a mean age of 54 years. Henriet's technique was used in 23 patients until 1996, and was then modified the last 8 patients in order to create a continent valve. The diversion was performed after cystectomy for bladder or gynaecological tumour in 23 cases and 1 urinary tract reconstruction in 8 cases (neurogenic bladder, destroyed urethra, conversion of Bricker diversion).

RESULTS

With a mean follow-up of 42 months (12 to 84), the perioperative mortality was 3.4% and immediate complications were 26%, justifying reoperation in 6.4%. Late complications predominantly consisted of disinvagination of the valve with a reoperation rate of 13%. No surgical revision for newly modified antireflux valves has been performed since 1996. The continence rate of the system, evaluated between 3 and 6 months, was 90%.

CONCLUSION

Kock's pouch is a delicate operation, clearly associated with a high morbidity in this series, as in the literature, although the results improved with experience. Indications must be confined to patients in good general condition, motivated for self-catheterization (ATS) and in whom the urethra cannot be used for bladder replacement.

Coloanal anastomosis for distal third rectal cancer: prospective study of oncologic results

PURPOSE

Jeopardizing cure and risking high local recurrence have served as arguments against sphincter-saving resection for patients with distal third rectal cancer. This prospective study examines and compares the local recurrence and survival rates in patients with distal third rectal cancer treated by either coloanal anastomosis or abdominoperineal resection.

METHODS

Between 1977 and 1993, 174 patients underwent coloanal anastomoses and 38 patients underwent abdominoperineal resection. All tumors were located 4 to 7 cm from the anal verge. One hundred ninety-three patients (91 percent) underwent rectal excision with a curative intent. Mean follow-up was 66 months after sphincter-saving resection and 65 months after abdominoperineal resection.

RESULTS

Mean anastomotic height from the anal verge was 2.3 cm after sphincter-saving resection. Overall local recurrence rate was 7.9 percent after sphincter-saving resection and 12.9 percent after abdominoperineal resection. The five-year actuarial survival rate was 78 percent after sphincter-saving resection and 74 percent after abdominoperineal resection.

CONCLUSION

Local recurrence and survival are not compromised in patients with distal third rectal cancer when treated by sphincter-saving resection, provided that oncologic principles are not violated. Coloanal anastomosis can be performed with an acceptable morbidity.