Coloanal anastomosis: indications and surgical technique

The coloanal anastomosis has evolved from the older "sleeve" pull through techniques and is used as a sphincter-saving procedure in those patients requiring excision of the rectum where adequate removal of all disease necessitates transection of the rectum close to the dentate line. For very low rectal carcinomas, however, abdominoperineal resection remains the procedure of choice for curative treatment. The appropriate choice of low anterior resection, coloanal pull through anastomosis, or abdominoperineal resection depends on many other variables besides the location of the tumor, and the correct choice may not be apparent until the rectum has been mobilized at surgery. The coloanal procedure requires wide excision of the lesion; full mobilization of the splenic flexure, distal transverse colon, and descending colon; precise transanal removal of the rectum; accurate suturing of the descending colon to the anus; and a temporary defunctioning colostomy. With careful technique, longterm results are good in most patients.     

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.     

Abdominosacral resection for midrectal cancer. A fifteen-year experience.

From 1966 to 1981, 646 patients underwent resection for primary adenocarcinoma of the rectum by one surgeon (S.A.L.) in one hospital. The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (ASR) in 320 patients, abdominosacral resection (ASR) in 175 patients, and abdominoperineal resection (APR) in 151 patients. The operative mortality rate was 2% following each of the operations. Anastomotic complications occurred in less than 2% after AR and in 9.7% after ASR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 419 of 427 patients treated from 1966 to 1976. Five-year survival for curative resection (no distant metastases) was 66.2% after AR (129/195), 62.9% after ASR (56/89), and 43.4% after APR (33/76). For patients with no tumor in lymph nodes, survival rates were 73.9% in AR, 75% for ASR, and 59.5% for APR. With involvement of regional lymph nodes, survival fell to 45.2% in AR, 37.9% for ASR, and 17.7% for APR. Pelvic recurrence was detected in 13.3% after AR, 14.6% after ASR, and 13.2% after APR. The authors believe that for midrectal cancer, ASR is the most reliable sphincter-saving procedure. It affords maximum exposure for wide resection of the tumor and safe anastomosis without disrupting the anal sphincters and their innervation. Sphincter preservation can be consistently preserved with no apparent increase in the risk of local recurrence or death from cancer.     

Quality of life of patients treated with abdominoperineal resection or anterior resection for rectal carcinoma

The functional results of surgery for rectal carcinoma were evaluated in 68 patients, 37 treated with anterior resection and 31 with abdominoperineal resection. The patients answered a questionnaire 8-84 months after surgery regarding bowel habits, urgency, incontinence and quality of life. Those who had undergone anterior resection had significantly more frequent bowel movements per day than those treated with abdominoperineal resection, and problems with urgency and flatus. Significantly more patients treated with anterior resection used medication to achieve normal bowel function. Despite the problems of frequent bowel movement, urgency, flatulence and the need for frequent medication, the patients who had undergone sphincter-saving procedures seemed to have a better quality of life than those treated with abdominoperineal resection.     

Abdominosacral resection of the rectum

Abdominosacral resection is the most reliable radical sphincter saving operation for midrectal cancers which are too low for anterior resection. The posterior incision provides maximum exposure for wide resection of the tumor, a measured distal margin, and an accurate anastomosis. The procedure can be carried out consistently to the pelvic floor without disrupting the anal sphincters and their innervation. Sphincter function is consistently preserved. The risk of abdominosacral resection is comparable to that incurred for anterior resection or abdominoperineal resection. Mortality rate is 2%. Morbidity can be limited by the selective use of a protective colostomy. The use of abdominosacral resection has extended sphincter saving resection to include 77% of 646 consecutive patients with rectal cancer. Abdominosacral resection provides the maximum clearance around the tumor and long term follow up has revealed no greater risk of local recurrence or death from cancer.     

Carcinoma of the rectum: a 10-year experience

A consecutive series of 303 patients with carcinoma of the rectum and distal sigmoid colon treated by a single surgeon over a 10-year period are reported. Of these, 202 underwent an anterior resection, 85 an abdominoperineal excision of the rectum and 16 a coloanal anastomosis. Surgery was considered palliative in 52 patients undergoing anterior resection and 24 undergoing abdominoperineal resection. The 30-day hospital mortality rate was six patients (3 per cent) for anterior resection and two patients (2 per cent) for abdominoperineal resection. Peroperative anastomotic testing demonstrated leakage in five stapled anastomoses; these were rectified and no clinical sequelae occurred. Two patients (1 per cent) developed a clinical anastomotic leak, one of which proved fatal; in each case the intraoperative test was negative. The overall 5-year survival rate was 64 per cent after anterior resection and 52 per cent after abdominoperineal resection; the median follow-up was 64 months. The incidence of local pelvic recurrence was 6.4 per cent after anterior resection and 14 per cent after abdominoperineal (not significant). These results confirm the success of sphincter-saving anterior resection combined with total mesorectal excision, routine full mobilization of the splenic flexure and cancercidal lavage of the distal rectum in the treatment of low rectal carcinomas; morbidity, local recurrence and survival are not compromised.     

Rectum carcinoma. Optimizing therapy by deep resection or excision]

Abdominoperineal excision of the rectum has been the surgical treatment of choice for rectal cancer of the middle and lower third for decades. However, subsequent to technical developments, particularly stapling instruments, sphincter saving procedures such as low anterior or intersphincteric resection superseded abdominoperineal excision in the majority of tumors of the middle and even lower third of the rectum. Within the last seven years (1990-1997), 253 patients with distal rectal cancer underwent surgery--in 204 patients surgery was carried out for the cure of malignancy, whereas in 49 patients surgery was performed for palliation. In the meantime, the rate of abdominoperineal excision with permanent stoma was steadily decreased from 25% (1990-1993) to 9% (1994-1997). Concerning oncologic quality, sphincter saving resections showed evidence that cure rates (3- and 5-year survival) were not compromised by these techniques; conversely, sphincter saving resections offered oncologic cure rates superior to abdominoperineal excision of the rectum. Complete lymphadenectomy with high ligation of the inferior mesenteric artery and total mesorectal excision (TME) are fundamental components of this approach. Moreover, the adverse effects of a permanent colostomy and the consecutively diminished quality of life following abdominoperineal excision can be avoided in approximately 80% of cases. In conclusion, at present 80-85% of rectal carcinomas of the middle or lower third can be surgically treated by sphincter saving low resections without compromising oncologic radicality.     

A comparison of published rates of resection margin involvement and intra‐operative perforation between standard and ‘cylindrical’ abdominoperineal excision for low rectal cancer

Aim The study aimed to compare recent reports on standard and alternative methods of abdominoperineal excision for low rectal cancer regarding the rates of circumferential resection margin involvement and intra‐operative bowel perforation. Method Data on rates of margin involvement and perforation were obtained from eight recently published reports and also from a prospective registry of resections at Concord Hospital. Rates of these outcomes and their 95% confidence intervals were evaluated. Results There was no evidence that extralevator abdominoperineal excision yielded significantly lower rates of resection margin involvement or intra‐operative bowel perforation compared with standard abdominoperineal excision in six independent hospital‐ and population‐based patient series. Abdominosacral resection of the rectum, on the other hand, did show significantly lower rates of these endpoints, albeit in selected patients. Conclusion The role of extralevator abdominoperineal excision and abdominosacral resection of the rectum should be investigated further in randomized controlled trials.     

Reconstruction of anorectal angle after abdominoperineal resection of rectum and anus--an animal model

Voluntary control of the bowel movements is a social necessity. Lack of control relegates one to psychological debility and the possible need for a permanent colostomy. Anorectal angle plays an important role in fecal continence. In the normal individual, this angle lies in the range of 60 to 105 degrees. Perineal colostomy, once proposed for patients who had received abdominoperineal resection (APR), has been abandoned because of frank incontinence. This study used a canine model. The anorectal angle, external sphincter, internal sphincter, and the puborectalis were all destroyed after APR. The colon was pulled through the perineal defect. Enteropexy, gracilis muscle transfer, and perineal colostomy were performed to restore the anorectal angle. Barium enema was performed preoperatively and postoperatively. The anorectal angle was reconstructed within normal ranges after abdominoperineal resection of the rectum and anus.     

Surgery of colorectal cancer

Studies on lymphatic spread of rectal cancer have established the rationale for sphincter preservation in the treatment of midrectal cancer. This entity comprises lesions located 5.5 to 10 cm above the anal verge in women and 7 to 11 cm in men. Abdominosacral resection is a logical means for restoring intestinal continuity after radial resection for midrectal cancer. Direct posterior exposure of the distal limit of resection above the pelvic floor allows accurate construction of the anastomosis without disturbing the anorectal structures or their innervation and maintains essentially normal anal continence. The procedure is preferable to the various pull-through operations. Survival rates for patients undergoing anterior resection, abdominosacral resection and abdominoperineal resection are comparable.     

Abdominosacral Resection for Carcinoma of the Midrectum: Ten Years Experience

Abdominosacral resection allows curative resection of midrectal cancer with excellent preservation of sphincter function. In the last ten years 427 patients underwent resection for rectal carcinoma at University Hospital by one surgeon. (SAL) The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (AR) in 239, abdominosacral resection (ASR) in 100, and abdominoperineal resection (APR) in 88. Operative mortality was 1.7% for AR, 2% for ASR and 2.3% for APR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 194 of 195 patients treated five to ten years ago. Five year survival for curative resection (no distant metastases) was 67.3% after AR (66/98), 58.3% after ASR (21/36), and 50% after APR (15/30). For patients without tumor in lymph nodes, survival rates were 78.3% for AR, 64.3% for ASR and 63.2% for APR. With involvement of regional nodes, survival fell to 41.4% for AR, 37.5% for ASR and 27.3% for APR. For lesions at 5-8.5 cm, five year survival was 61.1% for ASR and 58.3% for APR. No statistical difference in survival time was noted when patients were matched for age, sex, level of lesion and extent of spread. Pelvic recurrences were detected in 16.7% after ASR, 15.3% after AR and 33.3% after APR. All of the pelvic recurrences after ASR and the majority of those after AR and APR occurred in patients with tumor invasion of perirectal fat. These data strongly support the applicability of ASR as an important advance in the treatment of midrectal cancer. Although technically demanding, ASR has permitted preservation of anal continence without sacrifice of long-term cure in approximately 50% of patients who would otherwise have required APR.     

Rectal resection for tumour with transanal anastomosis and sphincter preservation.

Resection of the rectum, with restoration of continuity by means of a primary, transanal, anocolic anastomosis, is a useful method in the treatment of certain rectal tumours. It particularly fills a need in the management of tumours of the lower rectum where anterior resection is indicated but is technically difficult and liable to complications, or where it is not possible and would be abandoned in favour of abdominoperineal excision of the rectum with a permanent colostomy. The pathological criteria, technical factors and functional results which justify the use of this procedure are discussed. The principles of the operation are described, and 2 illustrative cases are reported. The large size, low site and pathological nature of both the malignant carcinoid tumour and the leiomyoma were such that total rectal resection was obligatory, the object being palliation in the former and cure in the latter. Both patients were continent after the operation. The place of this operation in the treatment of adenocarcinoma of the rectum is discussed.     

Declining indications for abdominoperineal resection

In 126 consecutive patients operated on for carcinoma of the lower two-thirds of the rectum, a consistent policy of sphincter preservation resulted in 100 (79 per cent) having anterior resection and 22 (17 per cent) abdominoperineal resection. Perioperative complications in the anterior resection group were: death (two patients), clinical leakage (three patients), pulmonary embolism (five patients), pelvic haematoma (one patient), small bowel obstruction (one patient) and wound sepsis (six patients). Of 55 patients who had a potentially curative anterior resection with follow-up of at least 2 years, one developed local recurrence. Five per cent of patients had significant continence problems. Low anterior resection for carcinoma is associated with low perioperative morbidity, satisfactory functional results and acceptable local recurrence rates.     

直肠癌合并肝转移时原发肿瘤的手术选择及其疗效评估

目的:回顾性分析本院收治的直肠癌合并肝转移病例,探讨直肠原发灶手术的不同方式。方法：1991年10月～1999年10月,收治直肠癌伴肝转移病例43例,其中男30例,女13例,年龄33～75岁;原发肿瘤位于直肠上段者9例,中段者14例,下段者20例。依据原发肿瘤部位,采取不同的术式,其中直肠前切除者14例,Miles手术者11例,Hartmann手术者7例,结肠造口者11例。结果：全组死亡31例,中位生存时间：直肠前切除者13.8个月,Miles手术者13.7个月,造瘘术者9.2个月;现尚生存者12例(27.9%),均达一年以上,有2例存活8年,仍在继续随访中;肿瘤未切除而作造瘘术者均已死亡。结论：直肠癌合并肝转移时,对原发肿瘤的处理应采用积极治疗手段,以期延长生存期、改善生存质量。     

Treatment of rectal carcinoma: our experience

Authors' experience with 53 patient operated on for adenocarcinoma of the rectum in Oncologic Surgery Department--University of Messina (Italy) was analysed. The development of mechanical devices has allowed surgeons to perform sphincter-saving in patients with medium-lower tumors of the rectum. In this experience abdominoperineal amputation was performed in cases of distal rectal tumors, local transanal excision was performed in 6 cases. There were no statistically significant differences between low anterior resection and abdomino-perineal resection with respect to local (17% vs 16.6%) and distant (16% vs 16%) recurrence.     

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.Presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Passagere Kolostomieanlagen nach Eingriffen am Colon Sigmoideum und Rektum—Sind Sie Noch Gerechtfertigt?

Primary anastomosis is increasingly favored even in emergency colorectal surgery. Two-stage procedures are frequently considered obsolete. The aim of this study is to define conditions when a two-staged operative strategy with a temporary colostomy is still appropriate. We analyzed a series of 126 patients who were treated by a colostomy following resection and subsequent closure of the colostomy. In 44 cases the primary operation was a Hartmann resection, in 39 cases a resection with colostomy and mucous fistula and in 43 cases a resection with primary anastomosis and proximal loop colostomy. Complications of diverticlar or neoplastic disease were generally managed by resection without primary anastomosis. Protective loop colostomy was done after low anterior resection of the rectum or in cases of anastomotic leakage. Patients were hospitalized again after an average of 6 months for closure of the colostomy. Restoration of intestinal continuity carried no significant risk of severe intra- or postoperative complications. Disturbances of wound healing occurred in 4.5% (Hartmann resection), 17.9% (colostomy and mucous fistula) and 20.9% (loop colostomy) of patients. We found an anastomotic dehiscence rate of 2.4% after discontinuity resections and of 4.7% after closure of loop colostomies. Only one patient with anastomotic leakage required surgical reintervention. The mortality after closure of a colostomy was zero. The rate of anastomotic leakage of 2.4% was lower than in published series with more than 7.2% after primary anastomosis, thus emphasizing the beneficial effect of a two-stage operative strategy. In emergency situations of sigmoidal and rectal surgery or in cases of low anastomosis of the distal rectum, unnecessary surgical complications can be avoided by resection without primary anastomosis or by performing protective loop colostomies.     

Low anterior resection of the rectum using a double stapling technique

Using a double stapling technique in 30 patients, anterior resection of the rectum was attempted for low rectal carcinoma (n = 28), giant rectal adenoma (n = 1) and radiation-induced rectal stricture (n = 1). There were three emergency operations. The rectum was stapled transversely more than 3 cm below the tumour using the adjustable-angle linear stapler (Roticulator). Colorectal or coloanal anastomoses were constructed using the EEA circular stapler introduced per anum through the anorectal stump staple line. Ten coloanal and 19 low rectal anastomoses were achieved. A protecting transverse loop colostomy was fashioned in one patient with coloanal anastomosis who developed a vaginal tear during the procedure. In one patient technical failure necessitated conversion to abdominoperineal excision of the rectum. All staple rings and resection margins were intact and free from tumour. There were two clinical anastomotic leaks, both treated successfully with a defunctioning transverse loop colostomy. One patient developed a small infective pelvic haematoma 2 weeks after surgery which required drainage. Hospital stay ranged from 6 to 15 days (mean 8 days). Continence was normal in all patients at 8 weeks. One soft coloanal anastomotic stricture required dilatation. No recurrences have been detected during a follow-up of between 10 and 22 months.     

Perineal colostomy: an alternative to avoid permanent abdominal colostomy: operative technique,results and reflection

Background

The most common injury to indicate definitive stoma is rectal cancer. Despite advances in surgical treatment, the abdominoperineal resection is still the most effective operation in radical treatment of malignancies of the distal rectum invading the sphincter and anal canal. Even with all the effort that surgeons have to preserve anal sphincters, abdominoperineal amputation is still indicated, and a definitive abdominal colostomy is necessary. This surgery requires patients to live with a definitive abdominal colostomy, which is a condition that modify body image, is not without morbidity and has great impact on the quality of life.

Aim

To evaluate the technique of abdominoperineal amputation with perineal colostomy with irrigation as an alternative to permanent abdominal colostomy.

Method

Retrospective analysis of medical records of 55 patients underwent abdominoperineal resection of the rectum with perineal colostomy in the period 1989-2010.

Results

The mean age was 58 years, 40 % men and 60 % women. In 94.5% of patients the indication for surgery was for cancer of the rectum. In some patients were made three valves, other two valves and in the remaining no valve at all. Complications were: mucosal prolapse, necrosis of the lowered segment and stenosis.

Conclusion

The abdominoperineal amputation with perineal colostomy is a good therapeutic option in the armamentarium of the surgical treatment of rectal cancer.     

An analysis of survival and treatment failure following abdominoperineal and sphincter-saving resection in Dukes' B and C rectal carcinoma. A report of the NSABP clinical trials. National Surgical Adjuvant Breast and Bowel Project

Abdominoperineal resections for rectal carcinoma are being performed with decreasing frequency in favor of sphincter-saving resections. It remains, however, to be unequivocally demonstrated that sphincter preservation has not resulted in compromised local disease control, disease-free survival, and survival. Accordingly, it is the specific aim of this endeavor to compare local recurrence, disease-free survival, and survival in patients with Dukes' B and C rectal cancer undergoing curative abdominoperineal resection or sphincter-saving resection. For the purpose of this study, 232 patients undergoing abdominoperineal resection and 181 subjected to sphincter-saving resections were available for analysis from an NSABP randomized prospective clinical trial designed to ascertain the efficacy of adjuvant therapy in rectal carcinoma (protocol R-01). The mean time on study was 48 months. Analyses were carried out comparing the two operations according to Dukes' class, the number of positive nodes, and tumor size. The only significant differences in disease-free survival and survival were observed for the cohort characterized by greater than 4 positive nodes and were in favor of patients treated with sphincter-saving resections. A patient undergoing sphincter-saving resection was 0.62 times as likely to sustain a treatment failure as a similar patient undergoing abdominoperineal resection (p = 0.07) and 0.49 times as likely to die (p = 0.02). The inability to demonstrate an attenuated disease-free survival and survival for patients treated with sphincter-saving resection was in spite of an increased incidence of local recurrence (anastomotic and pelvic) observed for the latter operation when compared to abdominoperineal resection (13% vs. 5%). A similar analysis evaluating the length of margins of resection in patients undergoing sphincter-preserving operations indicated that treatment failure and survival were not significantly different in patients whose distal resection margins were less than 2 cm, 2-2.9 cm, or greater than or equal to 3 cm. If any trend was observed, it appeared that patients with smaller resection margins had a slightly prolonged survival (p = 0.10). This observation was present in spite of the fact that local recurrence as a first site of treatment failure was greater in the group with less than 2 cm that it was in the greater than or equal to 3 cm category, 22% versus 12%. This increased local recurrence rate in the population with smaller margins was not translated into an in crease in overall treatment failure and had absolutely no influence on survival. It is suggested that local recurrence serves as a marker of distant disease.(ABSTRACT TRUNCATED AT 400 WORDS)