Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule

OBJECTIVE: To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge. SUMMARY BACKGROUND DATA: Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection. METHODS: From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy. RESULTS: Ninety-two patients with a tumor at 3 (range 1.5-4.5) cm from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2% and the 5-year overall and disease-free survival were 81% and 70%, respectively. CONCLUSIONS: The technique of intersphincteric resection permits us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. Tumor distance from the anal verge is no longer a limit for sphincter-saving resection.     

Incidence and patterns of recurrence after intersphincteric resection for very low rectal adenocarcinoma

BACKGROUND: The aim of this study was to evaluate the incidence and patterns of recurrence, or oncologic safety, after intersphincteric resection (ISR) without radiotherapy for very low rectal adenocarcinoma. STUDY DESIGN: One hundred eight consecutive patients with T1-T3 rectal cancers located 1 to 5 cm (median 3 cm) from the anal verge underwent ISR. A retrospective analysis of prospectively recorded data from the 106 patients not receiving radiotherapy was performed. RESULTS: There were 23 T1, 40 T2, and 43 T3 tumors. Morbidity and mortality rates were 33% and 1%, respectively. The 3-year rates of overall local recurrence and survival were 5.7% and 95%, respectively. The 3-year cumulative local recurrence rate was 0% for the patients with T1-T2 tumors as compared with 15% for those with T3 tumors (p=0.0012). In T3 tumors, the 2-year local recurrence rate was 5% for patients with negative surgical margins as compared with 33% for those with positive margins (p=0.0001). The incidences of distant recurrence for stages I, II, III, and IV disease were 4%, 5%, 18%, and 33%, respectively. CONCLUSIONS: ISR does not increase local or distant recurrences. For T1-T2 tumors, meticulous dissection and irrigation after closure of the distal stump allows local control without radiotherapy. With T3 tumors, preoperative therapy should be considered if resection margins are estimated to be insufficient.     

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients

OBJECTIVE: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. SUMMARY BACKGROUND DATA: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. METHODS: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. RESULTS: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. CONCLUSIONS: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.     

Concept de conservation sphinct��rienne dans la chirurgie du bas et du moyen rectum

Objective

To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge.

Summary background data

Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection.

Methods

From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy.

Results

Ninety-two patients with a tumor at 3 cm (range 1.5?C4.5) from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2%, and the 5-year overall survival and disease-free survival were 81% and 70%, respectively.

Conclusion

The technique of intersphincteric resection allows us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. The distance of tumor from the anal verge is no longer a limit for sphincter-saving resection.     

The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma

OBJECTIVE: To investigate the efficacy of preoperative short-term radiotherapy in patients with mobile rectal cancer undergoing total mesorectal excision (TME) surgery. SUMMARY BACKGROUND DATA: Local recurrence is a major problem in rectal cancer treatment. Preoperative short-term radiotherapy has shown to improve local control and survival in combination with conventional surgery. The TME trial investigated the value of this regimen in combination with total mesorectal excision. Long-term results are reported after a median follow-up of 6 years. METHODS: One thousand eight hundred and sixty-one patients with resectable rectal cancer were randomized between TME preceded by 5 x 5 Gy or TME alone. No chemotherapy was allowed. There was no age limit. Surgery, radiotherapy, and pathologic examination were standardized. Primary endpoint was local control. RESULTS: Median follow-up of surviving patients was 6.1 year. Five-year local recurrence risk of patients undergoing a macroscopically complete local resection was 5.6% in case of preoperative radiotherapy compared with 10.9% in patients undergoing TME alone (P < 0.001). Overall survival at 5 years was 64.2% and 63.5%, respectively (P = 0.902). Subgroup analyses showed significant effect of radiotherapy in reducing local recurrence risk for patients with nodal involvement, for patients with lesions between 5 and 10 cm from the anal verge, and for patients with uninvolved circumferential resection margins. CONCLUSIONS: With increasing follow-up, there is a persisting overall effect of preoperative short-term radiotherapy on local control in patients with clinically resectable rectal cancer. However, there is no effect on overall survival. Since survival is mainly determined by distant metastases, efforts should be directed towards preventing systemic disease.     

Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection

OBJECTIVE: Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. METHOD: Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. RESULTS: Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively CONCLUSION: For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival.     

Local Recurrence following Total Mesorectal Excision with Double-stapling Anastomosis for Rectal Cancers: Analysis of Risk Factors

This study reviewed the local recurrence rate in patients who had undergone total mesorectal excision and double-stapling low anterior resection for mid and distal rectal cancers. It also aimed to identify risk factors for local recurrence through univariate and multivariate analyses. Consecutive patients with rectal cancers within 12 cm of the anal verge treated with total mesorectal excision and double-stapling low anterior resection from August 1993 to December 2000 were studied. The demographic data, operative details, tumor characteristics, and follow-up data were collected prospectively. Factors that might affect the local recurrence rate were analyzed with univariate and multivariate analyses. A total of 270 patients were included in the study (156 men, 114 women). The mean +/- SD age was 64.83 +/- 11.27 years. The mean +/- SD level of the tumor was 7.17 +/- 1.90 cm. All anastomoses were performed within 5 cm of the anal verge. During the mean follow-up of 35.5 months, 12 patients developed local recurrence. The 5-year actuarial local recurrence rate was 7.3%. The presence of lymphovascular invasion and the resection margin of < or = 1 cm were found to be risk factors for local recurrence in the univariate analysis. In the multivariate analysis, the presence of lymphovascular invasion was the only independent factor for local recurrence. In the group of patients with lymphovascular invasion, proximal tumors (6-12 cm from the anal verge) were shown to have a significantly lower local recurrence than those within 6.1 cm from the anal verge (4.2% vs. 37.8%; p <0.001). Low anterior resection performed with double stapling and total mesorectal excision achieved a local recurrence rate of 7.3%. The presence of lymphovascular invasion was the only independent risk factor for local recurrence. A high local recurrence rate was associated with distal cancers (? 6 cm from the anal verge) with lymphovascular invasion. Adjuvant therapy for local control should be considered for this subgroup of patients.     

直肠癌局部切除术54例疗效分析

目的 探讨直肠癌局部切除的手术方式及疗效。方法 回顾分析1975-2000年间局部切除治疗直肠癌54例的临床资料。结果 局部切除术式包括经肛局部切除44例、经骶局部切除6例、经肛门括约肌局部切除２例及经阴道局部切除2例。48例肿瘤直径≤３cm,6例＞３cm。本组高分化腺癌48例，中分化腺癌６例；肿瘤浸润浅肌层（T2）8例。术后１例发生吻合口瘘、2例发生排便障碍，２例发生肠道出血。术手所有病例均接受放疗化疗，随访中2例局部复发（15%），复发时间为术后42(10-84)个月，复发病例再次行Miles手术。本组病例5年生存率为85%(45/53),10年生存率为55%(29/53),包括T1病变者分别为87%(39/45)及69%(27/39),T2分别为75%(6/8)及33%(2/6)。结论 只要适应症选择得当，局部切除术治疗直肠癌可取得与根治术类似的疗效。     

Impact of total mesorectal excision on the results of surgery of distal rectal cancer.

BACKGROUND: This study reviewed the results of surgery for distal rectal cancer (tumours within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution. METHODS: Two hundred and five patients who had undergone surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected prospectively. Comparisons were made between patients who had different surgical procedures. RESULTS: Abdominoperineal resection (APR) was performed in 27.8 per cent of patients, falling from 36.0 per cent in the first 3 years to 20.0 per cent in the last 3 years of the study. The overall operative mortality rate was 1.5 per cent and the morbidity rate 30.2 per cent. With a mean follow-up of 36 months, local recurrence occurred in 28 of the 185 patients who had curative resection. The 5-year actuarial local recurrence rates for double-stapled anastomosis, peranal coloanal anastomosis and APR were 11.2, 34.6 and 23.5 per cent respectively. The local recurrence rate was significantly lower for double-stapled low anterior resection than for the other types of operation. The overall 5-year survival rate in patients with low anterior resection and APR was 69.1 and 51.1 per cent respectively (P = 0.12). CONCLUSION: With the practice of total mesorectal excision, APR was necessary in only 27.8 per cent of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was much lower in patients with double-stapled low anterior resection than in those treated with APR or peranal anastomosis.     

Transanal endoscopic microsurgery for carcinoma of the rectum

Background The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM). Methods This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit. Results For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48–93 years). The median diameter of the lesions was 3.44 cm (range, 1.6–8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3–15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20–150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22–82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred. Conclusions The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.     

Preoperative Radiochemotherapy and Sphincter-Saving Resection for T3 Carcinomas of the Lower Third of the Rectum

OBJECTIVE: To evaluate the complications and oncologic and functional results of preoperative radiochemotherapy and sphincter-saving resection for T3 cancers of the lower third of the rectum. SUMMARY BACKGROUND DATA: Carcinomas of the lower third of the rectum (i.e., located at or below 6 cm from the anal verge) are usually treated by abdominoperineal resection, especially for T3 lesions. Few data are available evaluating concomitant chemotherapy with preoperative radiotherapy for increasing sphincter-saving resection in low rectal cancer. METHODS: Between 1995 and 1999, 43 patients underwent preoperative radiochemotherapy with conservative surgery for a low rectal tumor located a mean of 4.5 cm from the anal verge (range 2-6); 70% of the lesions were less than 2 cm from the anal sphincter. There were 40 T3 and 3 T4 tumors. Patients received preoperative radiotherapy with a mean dose of 50 Gy (range 40-54) and concomitant chemotherapy with 5-FU in continuous infusion (n = 36) or bolus (n = 7). Sphincter- saving resection was performed 6 weeks after treatment, in 25 patients by using intersphincteric resection. Coloanal anastomoses were associated with a colonic pouch in 86% of the patients, and all patients had a protecting stoma. RESULTS: There were no deaths related to preoperative radiochemotherapy and surgery. Acute toxicity was mainly due to diarrhea, with 54% of grade 1 to 2. Four anastomotic fistulas and two pelvic hematomas occurred; all patients but one had closure of the stoma. Distal and radial surgical margins were respectively 23 +/- 8 mm (range 10-40) and 8 +/- 4 mm (range 1-20) and were negative in 98% of the patients. Downstaging (pT0-2N0) was observed in 42% of the patients (18/43) and was associated with a greater radial margin (10 vs. 6 mm; P =.02). After a median follow-up of 30 months, the rate of local recurrence was 2% (1/43), and four patients had distal metastases. Overall and disease-free survival rates were both 85% at 3 years. Functional results were good (Kirwan continence I, II) in 79% of the available patients (n = 37). They were slightly altered by intersphincteric resection (57 vs. 75% of perfect continence; NS) but were significantly improved by a colonic pouch (74 vs. 16%; P =.01). CONCLUSIONS: These results suggest that preoperative radiochemotherapy allowed sphincter-saving resection to be performed with good local control and good functional results in patients with T3 low rectal cancers that would have required abdominoperineal resection in most instances.     

Comparison between straight and J-pouch coloanal anastomoses in surgery for rectal cancer

Abstract. Purpose: This study was designed to compare the long-term results of straight and J-pouch coloanal anastomoses after resection of rectal cancers located in the critical position of 5–6 cm from the anal verge. Methods: The subjects of this study were 81 patients who underwent radical resection of rectal cancers located 5–6 cm from the anal verge, followed by straight or J-pouch coloanal anastomosis, performed in 41 and 40 patients, respectively. Careful clinical and manometric follow-up was conducted and the results were compared. Results: There were no differences in the incidence of local recurrence, the disease-free survival rate, postoperative stool frequency, continence, sphincter pressures, or functional length between the two groups. Both groups had a high incidence of clustering or fragmented defecation; however, the J-pouch patients had better urgency control, a greater capacity before feeling the urge to defecation, superior rectal tolerance, and better compliance. Conclusions: Both straight and J-pouch coloanal anastomoses are oncologically and functionally acceptable for the treatment of rectal cancer located 5–6 cm from the anal verge, but the J pouch has slight superiority in urgency control, as a result of larger urge threshold and tolerable volume, and better compliance. The reason for the high incidence of clustering defecation in both groups needs to be investigated. Received: May 29, 2001 / Accepted: November 20, 2001     

经肛门括约肌间直肠切除结肠肛管吻合术作为超低位直肠癌保肛术的初步报告

目的 探讨经肛门括约肌间直肠切除结肠肛管吻合术（PIDCA)联合术前后放疗和化疗对超低位直肠癌保肛手术的治疗效果。方法从2002年6月到2004年10月,对19例患者施行该手术。男性11例,女性8例,平均年龄56岁(41-74岁)。肿瘤分期T,4例、T2 10例、T14例、L1例,肿瘤距离肛缘平均4．4cm(3．5-5．0cm)。经肛门在直视下从距离肿瘤下缘2cm全层切断直肠或肛门内括约肌,通过肛门内外括约肌间隙向上方游离直肠并与经腹完成的直肠游离汇合切除直肠及其系膜,经肛门行结肠肛管吻合,全部患者均未行预防性结肠或回肠造口。结果无手术死亡,吻合口瘘2例(10．5%)。随访时间为3～29个月,平均随访16个月,1例盆腔复发,复发率5．3％。术后肛门括约肌功能比较满意。结论对经过选择的距离肛缘≤5cm的超低位直肠癌结合术前后的盆腔放疗和化疗,PIDCA术是保留肛门括约肌功能较理想、安全的术式,有较好根治性治疗效果,术后肛门括约肌功能比较满意。     

First thousand rectal cancer cases--local recurrence and survival

In the period 1990 - 2002, 1674 patients with colorectal carcinoma were operated in the First Surgical Clinic, Third Department for Colorectal Surgery. In 1264 cases (75.5%) rectal carcinoma was the indication for surgical treatment. Sphincter saving procedures (SSP) were performed in 824 (65.2%), abdominoperineal resections (APR) in 340 (26.9%) and resections of rectum with definitive stoma (Hartmann procedure) in 100 (7.9%) patients. We analyzed 1095 cases where curative SSP or APR were performed. All cases where curative resection was not possible because of liver metastases or inability to excise all macroscopic disease were excluded. In the group of patients where SSP was performed (767 cases), there were 26.6% high colorectal anastomoses (8cm from anal verge), 65.4% with low (4-8cm from anal verge) and 8.0% with intersphincteric coloanal anastomosis (cm from anal verge). Patohistological exam showed 5.3% Dukes A, 53.1% Dukes B, 36.5% Dukes C and 4.9% Dukes D. In the APR group (328 cases) there were 1.,5% Dukes A, 32.4% Dukes B, 62.1% Dukes C and 3.5% Dukes D. In this study we analyzed local recurrence and five-year survival in both groups. Recurrence of the disease was registered in 325 (29.6%) out of 1095 patients. Local recurrence was found in 81 (7.,4%) patients. In the SSP group recurrence occured in 215 (28.0%) out of 767 curative resections. Local recurrence alone was found in 53 patients (6.9%). SSP group was also divided into two subgroups; in the first group TME was performed and in second transection of mesorectum was carried out. Analyzing local recurrence in these two groups, in the TME group it was 7.6% and in the transection group 5.6%. In the APR group recurrence was registered in 110 (33.5%) out of 328 patients while local recurrence alone was found in 28 (8.5%) cases. Analyzing mortality we found that 234 (21.4%) out of 1095 patients died during follow-up. In the SSP group 154 out of 767 patients (20.1%) died. In the TME group mortality was 21.7% and in the transection group 16.9%. Mortality in the APR group showed that 80 out of 328 (24.4%) patients died during follow-up. Analysis by the Kaplan-Meier's test shows cumulative survival of 0.69 for all cases. In the SSP group cumulative survival is 0.72 and in the APR group 0.64 with statistically significant difference (p .001). In the TME group cumulative survival is 0.75 and in the transection group 0.,72 with statistically significant difference (p .05). We believe that performing SSP should be encouraged whenever it is possible because there is no difference in local recurrence rates and survival compared to APR. Transection of mesorectum can safely be performed in most cases with tumors located more than 8 cm form anal verge. We believe that exact preoperative staging and preoperative radiotherapy could improve results.     

Surgery treatment of rectal cancer

Surgical resection is the only curative procedure for carcinoma of the rectum. Heald's development of total mesorectal excision has made it the standard approach for mobile, non-fixed tumors; it permits optimal local control with less than 10% local recurrence at five years and minimizes nerve damage and genito-urinary complications. Although initial short-term results of laparoscopic approaches are very promising, the final role of laparoscopy has not yet been established. Neo-adjuvant radiotherapy should be proposed for locally advanced (T3, T4, and/or N+) tumors of the low and mid-rectum. Radiochemotherapy coupled with intersphincteric dissection offers hope for sphicter-sparing extirpation of even the lowest of rectal cancers. Local resection through a trans-anal approach may be considered for small (<3 cm.), mobile, well-differentiated tumors lying within 8 cm. of the anal verge if rectal echo-endoscopy shows an in-situ tumor or a T1 lesion with no evidence of lymphadenopathy. Future strategies may enlarge the indications for local resection if and when radiochemotherapy can achieve a complete local response (tumor sterilization).     

Local excision of rectal carcinoma

Sixteen published series were reviewed in which local excision was used as definitive treatment for patients with invasive rectal carcinoma located within 6 cm of the anal verge. Ninety-four percent of tumors were T1 or T2 adenocarcinomas with no identified regional metastases. Five-year cancer-specific survival was 89%. Local recurrence was 19%, although more than half of these patients were cured with additional surgery. These results were comparable with those for historical controls treated with abdominoperineal resection (APR). Four pathologic features of the surgical specimen were analyzed to assess their correlation with patient outcome. Positive surgical margins, poorly differentiated histology, and increasing depth of bowel wall invasion were associated with increased local recurrence and decreased survival. Tumor size greater than 3 cm was not a significant factor. When criteria for appropriate patient selection are followed, local excision may provide survival and recurrence rates comparable with those achieved with APR with less morbidity and operative mortality.     

Role of intersphincter resection among the surgical options for cancer of the distal rectum

The surgical treatment of low rectal cancer has yet to be standardised. The aims of the study were to define the curative role of intersphincteric resection and to evaluate its indications and functional results through a retrospective clinical experience. From 1988 to 2000, out of 783 operations for primary rectal cancers (resectability rate 96%; restorative resections 83% and APR 10%) an intersphincteric resection was performed in 48 patients (31 male, 17 female, average age 62) for tumours located at a mean distance of 4.5 cm from the anal verge. Clinical stage: 27 T3 (56.3%), 12 T2, 5 T4 and 4 T1. All the operations were rated R0. TME with N-S, endo-anal distal transection and manual colo-anal anastomosis with a protective stoma were systematically performed. The mean follow-up was 46 months (range: 12-80). Functional results were evaluated with a prospective standardised questionnaire. There was no hospital mortality (30 days). The total morbidity rate was 22% with anastomotic leakage (clinical or X-ray evidence) in 12.5%. Four anal stenoses needed dilatation. Only one local recurrence six years after operation (2.1%). Nine patients died of systemic metastases within 3 years of surgery; the others are still alive and disease-free. Minor faecal incontinence with frequency and urgency occurred in 68.7% of cases at 3 months after protective stoma closure and in 37.5% after 6 months. After one year continence was good in 85.4% of survivors. Only one case required a permanent stoma for poststenotic total incontinence. The best functional results were achieved by colonic pouch reconstruction. For selected low rectal cancers (T2/T3) without voluntary sphincter infiltration, intersphincteric resection is safe and effective for oncological and functional purposes. The procedure requires accuracy in dissecting the anorectal junction. Preoperative radiotherapy may increase the indications for intersphincteric resection as well as the availability of a disease-free margin. A manual colo-anal anastomosis with colonic pouch interposition is strongly recommended.     

全直肠系膜切除术加改良Bacon手术治疗超低位直肠癌的临床研究

目的探讨全直肠系膜切除术(TME)加改良Bacon手术治疗超低位直肠癌的手术适应证和手术操作方法。方法对76例确诊为直肠癌的癌灶下缘距肛门缘4~8 cm的患者,采用自制肛门牵开器经腹腔和肛门途径行TME加改良Bacon手术。结果全组手术均成功,无手术死亡,无吻合口瘘,2例发生吻合口狭窄。术后随访76例1~5年,术后3~5个月开始恢复排便自控功能,为3~6次/d;6个月以后肛门排便功能基本恢复正常,为1~3次/d。其中5例于术后1~2年吻合口区域局部癌复发(6.58%);1,3,5年生存率分别为100%,80.83%和68.37%。结论TME加改良Bacon手术是一种治疗无远处转移的Dukes A~C期超低位直肠癌的安全有效的方法。