Anastomosis protection and preservation of continence in the surgical treatment of rectal carcinoma

AIMS: To find clues to a risk-adjusted therapy with regard to the use of protective colostomies and the value of Hartmann-resection. METHODS: In 108 patients with rectal cancer the results of surgical treatment were examined during a period from 1996 to 1998. RESULTS: One surgeon always performed a defunctioning colostomy in low anterior resection if the patients were male with lower and advanced tumors after preoperative radiation, while others carried out anastomotic protection in none of these patients. Anastomotic dehiscence never occurred in these patients, but in male patients with more proximal tumors and without preoperative radiation. Overall, preoperative radiation did not result in a higher rate of complications and local recurrence never occurred. Nineteen patients with high comorbidity underwent Hartmann-resection as a therapy with assumed lower risk for postoperative complications when compared with abdomino-perineal resection. The postoperative mortality rate of 16% was well above the mean postoperative mortality of 4.6%. Local recurrence occurred in 31% in comparison with 16% after abdomino-perineal resection, but all of these patients were operated on for obstructing node-positive T4-tumors. CONCLUSIONS: Technical difficulties in performing a low rectal anastomosis should be more important for the indication of anastomotic protection than generalizing guidelines. Preoperative short-term radiation is safe and has a beneficial effect on local recurrence. The Hartmann-resection is advisable only in patients with colonic obstruction and locally advanced tumors and in patients with a markedly higher comorbidity, in whom the risk of an anastomosis is not justified.