Hartmann's procedurevs. abdominoperineal resection for palliation of advanced low rectal cancer

In managing advanced low rectal adenocarcinomas in medically fit patients, surgical resection offers the best palliation. Tenesmus, bleeding per rectum, sacral pain, and sciatic pain are common complaints, which are not relieved by radiotherapy or fulguration. The most appropriate resection, however, remains controversial. Abdominoperineal resection is faster and simpler to perform but leaves behind a perineal wound with associated complications. Hartmann's procedure requires adequate mobilization below the tumor and may be technically more demanding but avoids a perineal wound. Therefore, an analysis of outcome in patients treated by Hartmann's procedure vs. abdominoperineal resection was made. METHOD: Fifty-four symptomatic patients with advanced rectal adenocarcinoma arising within a median of 5 (range, 4–8) cm from the anal verge treated between June 1989 and October 1995 were studied. Twenty-eight patients (17 males; mean age, 67.6±10.3 years) had Hartmann's procedure, and 26 patients (12 females; mean age, 68.8±8.3 years) were treated by abdominoperineal resection. Mean follow-up was 23.5 months (±17.5) and 18.6 months (±12.9) in Hartmann's procedure and abdominoperineal groups, respectively. RESULTS: Mean operative time was 138.4±26.7 minutes for Hartmann's procedure group and 124.6±27.1 minutes for the abdominoperineal resection group ( P >0.05; not significant). Postoperatively, Hartmann's procedure group started oral intake at a mean of 2.3 days, and stomas were functioning at a mean of 3.1 days compared with 2.6 days for oral intake and 3 days for stoma functioning in the abdominoperineal resection group. Hartmann's procedure group was ambulant after a mean of 2.4 days vs. a mean of 3.2 days in the abdominoperineal resection group. Postoperative abdominal wound infection occurred in 18 and 19 percent, respectively, in Hartmann's procedure and abdominoperineal resection groups. Forty-six percent of patients had perineal wound sepsis, and 38 percent had perineal wound pain in the abdominoperineal resection group. These complications were absent in Hartmann's procedure group. Postoperative stay was similar in both groups. CONCLUSION: We conclude that Hartmann's procedure offers superior palliation compared with abdominoperineal resection because it provides good symptomatic control without any perineal wound complications and pain.     

New perspective in the treatment of low rectal cancer: Total rectal resection and coloendoanal anastomosis

PURPOSE: Presently abdominoperineal resection still remains the most diffuse modality of treatment of low rectal cancer. However, a new surgical approach is now available to avoid such a demolitive surgery and a definitive colostomy. METHODS: From March 1990 to March 1993, 58 total rectal resections were performed in 55 patients affected with primary or recurring cancers of the low rectum. As a restorative procedure, a colic J-shaped pouch and a handsewn pouch-endoanal anastomosis was adopted. All of the primary lesions were within 7 cm of the anal verge; in 74 percent the distal tumor margin was located less than 6 cm from the cutaneous edge. RESULTS: Histologic clearance of the rectum cut edge was documented in all cases. Seven patients relapsed locally from 7 to 14 months after surgery and in 3 more cases distant metastases were documented. Postoperative morbidity is low. After colostomy closure in 78 percent of patients, perfect continence was achieved and in 74 percent less than two bowel movements a day were recorded. Fifty patients are presently alive, 46 without evidence of disease. The follow-up ranged from 2 to 37 (median, 13) months. CONCLUSION: This experience, along with data obtained from last year's literature, indicates that a conservative surgical procedure, such as total rectal resection and coloendoanal anastomosis, can be considered a feasible and radical option for treatment of low rectal cancer.     

Proctectomy and coloanal reconstruction for rectal cancer

There is increasing interest in the use of coloanal reconstruction following proctectomy for low rectal cancer. The authors review the surgical options for such sphincter-saving approaches, and report their pilot experience with eight patients receiving high-dose preoperative radiation with subsequent proctectomy and endoanal anastomosis. There were no anastomotic leaks.     

Anal sphincter reconstruction with a pudendal nerve anastomosis following abdominoperineal resection

PURPOSE AND METHODS: We report herein a case of a patient with rectal carcinoma in whom a new anus was constructed following an abdominoperineal resection of the anorectum. This is the first reported case in which reconstruction of the anal sphincter was performed using the lower part of the gluteus maximus muscle with a pudendal nerve anastomosis. The pudendal nerve anastomosis maneuver was designed to achieve proper innervation and function of the external anal sphincter. This newly reconstructed sphincter was physiologically evaluated after surgery. RESULTS: The patient's defunctioning colostomy was not closed following his initial surgery because part of the transposed muscle was devitalized by infection following blood flow damage. However, purposeful contraction of the new sphincter was easy to achieve without special training. The patient's rectal sensation for the desire to defecate was satisfactory. Electromyographic studies demonstrated that the newly reconstructed anal sphincter had characteristics of the original external anal sphincter. CONCLUSIONS: This method is a promising procedure for reconstructing the anal sphincter.     

Defecographic evaluation of dynamic graciloplasty for fecal incontinence

PURPOSE: A prospective defecographic study was performed to evaluate the anorectal physiology of dynamic graciloplasty (gracilis muscle transposition and subsequent implantation of an electric stimulator) for treatment of fecal incontinence. METHODS: From November 1986 until May 1993, 38 consecutive patients with incapacitating fecal incontinence were treated with anal dynamic graciloplasty. Defecography was performed before and after surgical procedures. Defecographic data (anorectal angle, perineal descent, anal canal length, anal canal width, and anal leakage) were correlated with respect to clinical outcome and anal manometry. RESULTS: Fecal continence was achieved in 24 patients, which correlated significantly with no leakage of barium contrast during defecography (P <0.01, Kruskal-Wallis one-way analysis of variance). In addition, minimum anal canal width decreased from 7 mm before surgery to 1 mm after dynamic graciloplasty (P<0.01, paired Student's t-test). CONCLUSION: Defecography is an efficient method to evaluate dynamic graciloplasty for fecal incontinence.Supported by the Ministry of Health and the Department of Trade and Industry, The Hague, The Netherlands.Read at the Scientific Assembly and annual meeting of Radiological Society of North America, Chicago, Illinois, November 27 to December 2, 1994.     

Urogenital dysfunction after abdominoperineal resection for carcinoma of the rectum

The long-term urogenital dysfunctions in 46 of 104 surviving patients submitted to abdominoperineal resection for rectal carcinoma between 1972 and 1986 were collected and assessed. Urinary retention was present in 41 percent of the men and 35 percent of women, while incontinence was present in 10 percent of men and 29 percent of women. Impotence was reported by 59 percent of the males, all sexually active before surgery. Dyspareunia was present in 50 percent of the women in the study. The possibility of treating prostatic hypertrophy concurrently with abdominoperineal resection in selected cases to avoid urinary retention is discussed. The limited number of responders to the survey may interfere with the global statistical significance.     

Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch

PURPOSE: Functional outcome after low anterior resection with ultralow coloanal anastomosis for rectal cancer is improved by construction of a colonic J-pouch vs. straight anastomosis. Optimum size of this pouch has yet to be determined. Therefore, we initiated a prospective, randomized trial using 5-cm and 10-cm pouches to determine this size. METHODS: Patients with tumors 5 to 10 cm from the anal verge were included in the study. Before a low anterior resection anastomosis was performed, patients were randomized to either a 5-cm J-pouch group (5-J group) or a 10-cm J-pouch group (10-J group). Functional assessments were performed one year postoperatively. Clinical functions were evaluated using a functional scoring system. Physiologic functions, such as sphincter and reservoir function, were evaluated by anorectal manometry and evacuation function by the balloon expulsion and saline evacuation tests. RESULTS: Forty patients among 43 randomized patients were assessed for functional outcome one year postoperatively (5-J group, n=20; 10-J group, n=20). The functional score was similar for the two groups, although reservoir function in the 5-J group was significantly less than in the 10-J group. Sphincter function was similar between the two groups. Evacuation function in the 5-J group was significantly superior to that in the 10-J group. CONCLUSIONS: The 5-cm J-pouch conferred adequate reservoir function without compromising evacuation.Supported, in part, by a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare and a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, and Science.     

Abdominoperineal resection and perineal colostomy for low rectal cancer

PURPOSE: We sought to evaluate a new technique for creation of a continent perineal colostomy following abdominoperineal resection (APR) of the rectum for low rectal cancer. METHODS: Nine selected patients with low rectal cancer (two males; median age, 55.6 years; classified as Dukes A, 6 patients and as Dukes B, 3 patients) underwent APR. Following this, the original Lazaro da Silva technique was used as follows: 1) for performance of three circular myotomies in the distal sigmoid with a distance between each couple of no more than 8 cm; 2) repair of the myotomies, thus creating three circular colonic valves, the most distal of which remained extraperitoneally; 3) for construction of a perineal colostomy lying flush with the perineal skin; 4) after the patient starts consuming a regular diet, enemas through the perineal stoma are done, usually twice per week, to achieve defecation. Functional outcome was assessed by evaluation of bowel movements and neoanal continence. RESULTS: There were no deaths. From January 1994 until October 1995, no tumor recurrence has occurred, and fecal continence has been good. Four of the patients were able to defecate without enemas (2–4 times per week), and in five patients the self-administration of enemas (2–4 times a week) were necessary to accomplish defecation. CONCLUSION: Initial results with the Lazaro da Silva technique have been encouraging.     

Dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection for rectal tumour

Aim To review the results of dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection (APR) for rectal cancer.Patients and methods Chart reviews were done on 17 patients who had dynamic graciloplasty following abdominoperineal resection and details of post-operative complications, bowel functions and recurrences were obtained.Results Seventeen patients (12 males) had dynamic graciloplasty after APR for low rectal tumours. The median age was 58.5 years (range 33–78). Three patients from overseas were lost to follow-up, and three still have not had the defunctioning stoma closed. Only 11 patients were available for evaluation of function. The median time from graciloplasty to continence to solids and liquids is 15.7 months (range 0.4–21.9 months). Six patients had defecatory problems, requiring daily irrigation to evacuate. Nine patients were continent without need for gracilis stimulation. Only two patients needed gracilis stimulation to maintain continence. Fifty percent of rectal carcinoma patients had developed a recurrence.Conclusion Dynamic graciloplasty had a high morbidity and did not always bring about normal defecatory function. Gracilis stimulation was not needed to achieve continence in all cases. Conversely, dynamic graciloplasty may lead to defecatory difficulties in a large number of patients. Graciloplasty should only be considered three years after the initial APR to avoid performing the procedure in a patient who may develop recurrence as well as to select patients who are psychologically prepared for the surgery and its complications.     

Colon and rectal cancer in pregnancy

Colorectal carcinoma presenting in pregnancy is an uncommon disease that is reported to be associated with an extremely poor prognosis. To better characterize this disease, we surveyed the membership of the American Society of Colon and Rectal Surgeons by mailed questionnaire and reviewed the literature. Forty-one new cases of women with large bowel cancer who presented during pregnancy or the immediate postpartum period were identified. The mean age at presentation was 31 years (range, 16–41 years). Tumor distribution was as follows: right colon-3, transverse colon-2, left colon-2, sigmoid colon-8, and rectum-26. Dukes stage at presentation was A=0, B=16, C=17, and D=6 (two patients were unstaged). Average follow-up was 41 months. Stage for stage, survival was found to be similar to patients with colorectal tumors in the general population. Large bowel cancer coexistent with pregnancy presents in a distal distribution (64 percent of tumors in the current series and 86 percent of those reported in the literature were located in the rectum) and presents at an advanced stage (60 percent were Stage C or more advanced at the time of diagnosis). While patient survival is poor, it is no different stage for stage from the general population with colorectal tumors.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Morphology of dynamic graciloplasty compared with the anal sphincter

Dynamic graciloplasty for fecal incontinence includes gracilis muscle transposition around the anal canal as a new sphincter and subsequent electrical stimulation. The aim of electrical stimulation is to transform the gracilis fast-twitch, fatigue-prone fibers into slow-twitch, fatigue-resistant fibers to achieve a sustained tonic contraction. The latter is considered essential for sphincter function. Therefore, the following features of transposed gracilis muscle morphology were studied in nine patients before and after electrical stimulation: 1) the percentage of Type I fibers, 2) the lesser diameter of these fibers, and 3) the positive collagen staining area. Furthermore, the external anal sphincter and gracilis muscle histology was investigated in six autopsy cases. The mean percentage of Type I, slow-twitch, fatigue-resistant fibers in transposed gracilis muscle increased from 46 percent before electrical stimulation to 64 percent (P <0.01, paired Student's t-test) after electrical stimulation. The mean lesser diameter of these fibers did not change significantly (from 32 to 29 m), and the mean percentage of collagen increased from 4 percent before electrical stimulation to 7 percent (P <0.01) afterward. The external sphincter in cadavers demonstrated a predominance of Type I fibers (80 percent) with a lesser diameter of 23 m and a high percentage (12 percent) of collagen. Gracilis muscle histology was uniform at six different sample sites in these cadaver dissections. We conclude that electrical stimulation induces histologic changes in transposed gracilis muscle, allowing this muscle to function as an external anal sphincter.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.These studies were financially supported by the Ministry of Trade and Industry and the Funds for Research in Medicine (Ontwikkelingsgeneeskunde), The Netherlands.     

Pelvic floor reconstruction after major cancer surgery

Background: Many surgical techniques to keep the small intestine out of the pelvis after cancer surgery have been developed. METHODS: We used part of the ileum and its mesentery sutured around the linea terminalis in ten patients who underwent surgery for rectal or gynecologic carcinomas. RESULTS: All imaging studies of our patients on the tenth postoperative day confirmed the position of the bowel above the pelvis. Four of ten patients had radiation treatment postoperatively without any problems. CONCLUSION: Use of the ileum to reconstruct the pelvic floor seems to be a simple and efficacious technique to keep the pelvic area free. We believe this warrants further investigation in a larger number of patients.     

Total anorectal and partial vaginal reconstruction with dynamic graciloplasty and colonic vaginoplasty after extended abdominoperineal resection

PURPOSE: Quality of life is altered after abdominoperineal resection, because of permanent iliac colostomy. Psychological rehabilitation is even more difficult after extended abdominoperineal resection to the vagina, because of the loss of both continence and sexual functions. We report the first case of total anorectal and vaginal reconstruction using dynamic graciloplasty and colonic vaginoplasty after extended abdominoperineal resection. METHODS: A 46-year-old female underwent extended abdominoperineal resection with posterior colpectomy for a low rectal adenocarcinoma infiltrating the anal sphincter and vagina. Anorectal reconstruction was performed with coloperineal anastomosis and double dynamic graciloplasty. Vaginal reconstruction was performed using a 10-cm, isolated, rotated sigmoid loop. The procedure was performed in three stages, including abdominoperineal resection with reconstruction, implantation of the stimulator, and closure of the temporary ileostomy. RESULTS: Resting and electrostimulated pressures of the neosphincter were 40 and 110 cm H2O respectively. Continence was achieved for formed stools two months after closure of the stoma, with spontaneous defecations (30-90 minutes). The patient experienced regular sexual activity six months after closure of the stoma. CONCLUSION: This new original technique can be proposed in selected young females after extended abdominoperineal resection, to preserve continence, sexual activity, and body image.     

Male sexual function after autonomic nerve-preserving operation for rectal cancer

PURPOSE: Sexual dysfunction after surgery of the rectum is a serious complication to male patients. Autonomic nerve-preserving operation for rectal cancer has been performed within the recent ten years to maintain urinary and male sexual functions without spoiling of therapeutic radicality. To clarify male sexual function as the degree of autonomic nerve-preserving operation, the function was outlined through clinical interview. METHOD: In a series of 134 male patients who were undergoing autonomic nerve-preserving operation for rectal cancer, a detailed history of postoperative sexual function was obtained by interviews. RESULTS: In 87.7 and 66.9 percent of patients, erectile and ejaculatory potencies were maintained, respectively, which were higher rates than those after extended and conventional pelvic dissections. According to the preserving extent of autonomic nerve, patients undergoing complete preserving operations showed higher rates of maintained erectile (92.9 percent) and ejaculatory functions (82.5 percent), sexual intercourse (89.9 percent), and orgasm (93.9 percent) compared with those undergoing hemilateral autonomic nerve-preserving (82.3, 47.1, 52.9, 64.7 percent) or partial pelvic plexus-preserving operation (61.1, 0, 26.3, 22.2 percent). CONCLUSION: Pelvic plexus preservation is necessary to maintain erectile potency, and both hypogastric nerve and pelvic plexus preservation are necessary to maintain ejaculate function and orgasm. To maintain satisfactory sexual function, complete autonomic nerve-preserving operation is suitable.Read at the meeting of the International Society of University Colon and Rectal Surgeons, Crete, Greece, October 25 to 29, 1992.     

Passivevs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma

PURPOSE: Because evacuation of effusion or collection could depend on the type of drainage, we compared the effects of closed suction drainage with passive drainage through tubes or undulated drains after abdominoperineal rectal excision for carcinoma on early and late perineal wound healing. METHODS: Of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma between January 1983 and August 1990, unsatisfactory hemostasis or gross intraoperative septic contamination were recorded in 48 patients who were not included in the trial. After rectal excision and closure of the perineum, the remaining 186 patients were randomized to receive passive drainage (PD; n=96) or closed suction drainage (SD; n=90). Eighteen patients were withdrawn because of protocol violation, and three were lost to follow-up, leaving 165 (89 PD and 76 SD) patients for analysis. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative and pathologic findings (Dukes stage), and postoperative courses (recurrence, late mortality) were similar in both groups. All patients were followed up for 12 months or until death. RESULTS: The rate of perineums healed at one month was significantly lower (P <0.05) in PD (55/89=61 percent) compared with SD (54/72=75 percent) patients. At three months, the rate of healed perineums no longer differed between the two groups (70/87=81 percent vs.60/72=84 percent). The number of vaginal fistulas, secondary reopenings, and perineums not healed at 12 months was similar in both groups. Median duration to complete healing was similar in both groups (23 vs. 21 days, respectively). On the other hand, three retained drains were seen in PD patients only. The median duration of hospital stay was identical in both groups (22 days). Seven patients died in the early postoperative period, including one in the PD group and six in the SD group. There was no significant difference in the number of late deaths (3 vs. 7) in PD and SD patients, respectively. CONCLUSION: These results suggest that closed suction drainage should be used after abdominoperineal rectal excision with satisfactory hemostasis or absence of gross intraoperative septic contamination.     

经腹肛门切除一期肛门原位再造治疗低位直肠癌

目的探讨低位直肠癌经腹、肛门切除，一期肛门原位再造的临床效果和实用性。方法对62例下段直肠癌行经腹肛门切除，一期肛门原位再造术的病例进行回顾和总结。结果62例病人中未发生再造肛门缺血坏死和狭窄、回缩。术后早期排便次数多，常在8～17次／d，无便意，口服止泻药、排便次数正常。术后28周养成定时排大便习惯，大便成形。病人有58例获得随访（随访率93．5％，58／62），平均随访4．0年，其中局部复发1例（1／58局部复发率17％）。3年生存数46例（生存率88．5％，46／52），5年生存数30例（生存率83.3％，30／36）。结论低位直肠癌经腹肛门切除、一期肛门原位再造是一种安全、可靠有效的直肠癌术式。     

Surgical adjuvant therapy for rectal cancer: Present options

Recent advances have been made with the publication of the results of GITSG and NCCTG trials, which demonstrated the significant improvement of survival by combined postoperative radiochemotherapy protocols for Stage II and III rectal cancer. These data show that systemic chemotherapy has a decisive role to play in this policy. Some of the advantages of preoperative irradiation compared with postoperative radiation therapy consist of the improvement of resectability of T4 tumors and the anal preservation for low-lying cancers. These data suggest that preoperative chemoradiotherapy should be applied not only to T4 tumors but also to all T3 tumors even when the transrectal extension is limited. The most usual protocol combines 5-fluorouracil (300–350 mg/m²/day) and leucovorin (20 mg/m₂/day) for 5 days, followed by radiation therapy (30–35 Gy in 10 fractions within 12–15 days), with surgery taking place 4 to 8 weeks later, after the tumor has been restaged. Systemic therapy is continued for four more months. T2 cancers should not be excluded from the benefit of preoperative irradiation.     

Decrease in the anorectal pressure gradient after low anterior resection of the rectum

PURPOSE: Changes in anorectal function after low anterior resection of the rectum (LAR) often lead to symptoms of urgency and frequency of defecation, the anterior resection syndrome. It has been reported that preservation of part of the rectum improves clinical results, but why this should be remains unclear. METHODS: We have carried out continuous ambulatory manometric studies in two groups of patients: 11 patients, a median of 11 (range, 5–96) months after LAR, in whom the median anastomotic level above the anal high-pressure zone was 0 (range, 0–2) cm; 9 patients, a median of 6 (range, 3–12) months after sigmoid colectomy, in whom the rectum remainedin situ and who acted as controls. RESULTS: Comparing the LAR group with controls, resting anal pressures were lower, median 68 (range 27-102) cm H₂Ovs. 95 (45–116) cm H₂O (P<0.05), and neorectal pressures were higher, 25 (0–48) cm H₂Ovs. 10 (0–10) cm H₂O (P<0.01). Thus the anorectal pressure gradients were less, 34 (0–74) cm H₂Ovs. 81 (35–113) cm H₂O (P<0.01). Slow-wave activity in the anal sphincter was present in six patients (55 percent) after coloanal anastomosis and eight patients (89 percent) after sigmoid colectomy. Sampling episodes were seen in only two patients (18 percent) after coloanal anastomosis and five patients (56 percent) after sigmoid colectomy. When clinical endpoints were compared (LARvs. controls), bowel frequency in 24 hours was higher, 5 (3–8)vs. 2 (1–3) (P<0.01); fecal leakage was more common, affecting seven patients (64 percent)vs. one patient (11 percent) (P<0.05), and urgency of defecation was also more common. CONCLUSIONS: The inferior clinical results observed after LAR compared with the results after sigmoid colectomy are thus in part because of higher neorectal pressure acting on a weakened sphincter mechanism. These observations lend support to the idea that neorectal capacity should be increased in patients who undergo low anterior resection.Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Causes of rectal incontinence after sphincter-preserving operations for rectal cancer

PURPOSE: Low anterior resection (LAR) is the treatment of choice for middle and high rectal tumors. Even though the rectal sphincter is preserved, some patients show a postoperative loss of rectal continence that may be recovered during follow-up. The purpose of this study was to collect clinical and manometric data before and after LAR to find possible explanations for incontinence. METHODS: Seventeen continent patients with rectal tumors located 10 cm above the anal verge were selected. Manometry was performed before and three months after surgery and when stable frequency of bowel movement was achieved (mean, 7 months). RESULTS: Immediately after the operations, 14 of 17 patients showed a certain degree of incontinence but recovered during follow-up; at the end of the study, only two patients reported minor soiling. Resting and squeeze pressures were moderately reduced after surgery and increased during the following six months without regaining preoperative levels. Rectoanal inhibitory reflex was present in 94.4 percent of patients before the operations and in 25 percent of them after surgery, but it was not associated with incontinence. Rectal sensation was significantly reduced, and its recovery was well correlated with decrease in the frequency of bowel movements. CONCLUSIONS: After LAR, there is a reduction in rectal pressures, suggesting damage to sphincter muscle fibers or innervation. There is also a reduction in rectal sensation related to loss in reservoir capacity, all of which may contribute to incontinence.Presented in part at the meeting of Preservation of the Pelvic Organs Function After Pelvic Surgery, Kyoto, Japan, July 22 to 23, 1995.     

Feasibility study for use of brush cytology as a complementary method for diagnosis of rectal cancer

Brush cytology has previously been described as a feasible method for accurately diagnosing colorectal cancer. PURPOSE: This study was designed: 1) to determine the sensitivity and specificity of brush cytology for the diagnosis of rectal cancer; 2) to prospectively assess the extent of interobserver variability with this technique; 3) to prospectively examine the cost impact of the addition of brush cytology as a routine method of confirming the diagnosis of rectal cancer. PATIENTS AND METHODS: Three hundred fiftyseven patients who attended a rectal clinic and who were found to have a lesion between January 1990 and March 1996 were assessed. Each patient underwent rigid proctoscopy, followed by brush cytology and tissue biopsy. Results were compared with the final histologic diagnosis in each patient. The brushings from the last 92 consecutive patients in this series were independently examined by four cytologists and a pathologist to determine the rate of interobserver variability. RESULTS: Rectal adenocarcinoma was confirmed from surgically resected specimens in 303 patients. Brush cytology accurately diagnosed 278 of them. Of the remaining 25 patients, two had brushings that were insufficient for diagnosis. There was one false-positive case. Forceps biopsy correctly identified cancer in 260 patients, with no false-positive interpretations. Brush cytology accurately identified 53 of 54 adenomas as being benign, and forceps biopsy correctly identified all as benign. Sensitivity of brush cytology in this series was 92 percent, with a specificity of 92 percent. Interobserver agreement was 84 percent. Actual costs incurred with this method was an additional $17.00 per patient. CONCLUSIONS: Brush cytology can accurately diagnose rectal cancer in a high proportion of patients. Interobserver variation is low and compares favorably with other forms of cytologic interpretation. The additional cost remains a concern but can be kept within acceptable proportion.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.