Coloanal anastomosis for distal third rectal cancer

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.     

Long-term functional outcome after low anterior resection

OBJECTIVE: The purpose of this study was to compare long-term functional results of two methods of reconstruction after anterior rectal resection for cancer: low colorectal anastomosis and colonic J-pouch-anal anastomosis. SUMMARY BACKGROUND DATA: After anterior resection for mid or low rectal cancer, the decision to perform low colorectal or coloanal anastomosis is made intraoperatively, depending on the distance of the tumor from the anal verge. Functional results of these operations are considered to be similar one to two years after surgery. No study to date has compared long-term functional results after rectal excision followed by either low colorectal anastomosis or colonic J-pouch-anal anastomosis. METHODS: From 1987 to 1992, 173 patients underwent anterior resection for cancer located between 2 to 12 cm from the anal verge. All patients alive without recurrence were contacted by telephone interview for assessment of functional results. There were 47 patients with colonic J-pouch-anal anastomosis and 34 patients with low colorectal anastomosis. Minimum follow-up was three years for all patients (mean, 5 years). RESULTS: The two groups were well matched for gender, age, histologic stage, and use of adjuvant therapies. Patients with colonic J-pouch-anal anastomosis displayed significantly better function in terms of frequency of defecation (1.57±1vs. 2.79±1;P=0.001) and presence of irregular transit or stool clustering (30vs. 71 percent;P=0.003). Patients who underwent colonic J-pouch-anal anastomosis were significantly less likely to require constipating agents (4vs. 21 percent;P=0.03) or need to follow a estricted diet (14vs. 41 percent;P=0.01). Results concerning the need to defecate again within one hour and disruption of social or professional life as a consequence of surgery showed a tendency in favor of colonic J-pouch-anal anastomosis. CONCLUSION: Colonic J-pouch-anal anastomosis offers superior long-term function compared with low colorectal anastomosis after radical treatment of rectal cancer. Preservation of a short rectal segment followed by a straight colorectal anastomosis does not offer any clinical advantage over colonic J-pouch-anal anastomosis.Poster presentation at the Digestive Disease Week and the meeting of the American Gastroenterological Association, Washington, D.C., May 11 to 14, 1997.     

Locally recurrent rectal cancer

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio Texas, May 2 to 7, 1998.     

Selective total mesorectal excision for rectal cancer

PURPOSE: Total mesorectal excision has been advocated for rectal cancer, but its use in upper rectal and rectosigmoid tumors remains a point of debate. METHODS: One hundred seventeen patients with rectal cancers were subjected to a prospective policy of total mesorectal excision for mid and low rectal cancers and a wide (5 cm) distal margin mesorectal excision for upper rectal and rectosigmoid cancers. RESULTS: Forty-one patients underwent ultralow anterior resection, 10 underwent abdominoperineal excision, 64 had anterior resection and 2 had Hartmann's procedure. The median follow-up was 39 months. Forty-three patients had a defunctioning ileostomy. Three patients (7.3 percent) had anastomotic leaks after ultralow anterior resection with total mesorectal excision. Ninety-three patients had palliative resections. There were four locoregional recurrences in this group, giving an actuarial locoregional recurrence rate of 9.3 percent at five years. The actuarial locoregional recurrence rate after anterior resection was 6.5 percent at five years. The actuarial five-year cancer-specific survival rate was 81.4 percent at five years. CONCLUSION: These results demonstrate that a policy of wide excision of the mesorectum for upper rectal and rectosigmoid cancer and total mesorectal excision for mid and low rectal cancer is associated with a low locoregional recurrence rate and may be as efficacious as routine total mesorectal excision for all rectal cancers.     

A national strategic change in treatment policy for rectal cancer--implementation of total mesorectal excision as routine treatment in Norway. A national audit

INTRODUCTION: Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project—initiated in 1993—aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique. METHODS: This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery. RESULTS: The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four-year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group. CONCLUSION: A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.     

Outcome of primary and secondary ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis

PURPOSE: The aim of this study was to present Swedish experiences of the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis from the introduction in 1984. The study also compared the surgical and functional outcome of different anal continence preserving procedures: ileal pouch-anal anastomosis as primary surgery, ileal pouch-anal anastomosis as secondary surgery after colectomy and ileorectal anastomosis, and ileorectal anastomosis alone. METHODS: The material comprises all 120 patients with familial adenomatous polyposis reported to the Swedish Polyposis Registry who had undergone prophylactic colorectal surgery, including those operated on because of colorectal cancer from 1984 until the end of 1996. Anal continence preserving surgery was performed on 102 patients: 20 had ileal pouch-anal anastomosis as primary surgery at a median age of 24.5 years, 39 had ileal pouch-anal anastomosis as secondary surgery at a median age of 34 years, and 43 had ileorectal anastomosis alone, at a median age of 26 years, because 6 of the initially ileorectal anastomosis-operated patients were converted to ileal pouch-anal anastomosis as secondary surgery. Surgical outcome was assessed on the basis of hospital records. A questionnaire was used to evaluate the functional outcome. Fisher's exact probability test was used for statistical analysis. RESULTS: Complications occurred in 51 percent of the patients after ileal pouch-anal anastomosis: 40 percent after ileal pouch-anal anastomosis as primary surgery and 56 percent after ileal pouch-anal anastomosis as secondary surgery. When the previous ileorectal anastomosis was taken into account 67 percent of the patients suffered complications which was significantly more compared with ileal pouch-anal anastomosis as primary surgery. After ileorectal anastomosis, 26 percent had complications which was significantly less compared with all other procedures but ileal pouch-anal anastomosis as primary surgery. No cancer occurred after ileal pouch-anal anastomosis, either in the ileal pouch or in retained rectal mucosa, but two of the patients who had an ileorectal anastomosis developed rectal cancer. One pouch excision was performed compared with ten rectal excisions. Functional outcome did not differ between ileal pouch-anal anastomosis as primary surgery and ileal pouch-anal anastomosis as secondary surgery. However, ileorectal anastomosis-operated patients had significantly better bowel function with regard to nighttime stool frequency, continence and perianal soreness. CONCLUSION: These findings indicate that major advantages of ileal pouch-anal anastomosis are the low excision rate and, so far, no cancer in the ileal pouch. Moreover, the surgical outcome of ileal pouch-anal anastomosis as primary surgery is not significantly different from that of ileorectal anastomosis. However, the good surgical and functional outcome of ileorectal anastomosis, despite the long-range prognosis including rectal cancer and excision risks, has to be taken into consideration when selecting patients with familial adenomatous polyposis for primary surgery.Parts of the functional outcome part of the study were presented at the Leeds Castle Polyposis Group meeting in Noordwijk, the Netherlands, June 4 to 7, 1997.Supported by the Cancer Society in Stockholm and the Karolinska Institute.     

Salvage radical surgery after failed local excision for early rectal cancer

OBJECTIVES: Local recurrence after transanal excision of rectal cancer is often amenable to salvage radical proctectomy, but the long-term results remain unknown. This study was designed to determine the outcome of salvage radical surgery after failed local excision in patients with early rectal cancer. METHODS: We retrospectively reviewed the charts of 29 patients who underwent salvage radical surgery for local recurrence after a full-thickness transanal excision for Stage I rectal cancer. End points included local and distant recurrences and disease-free survival after salvage radical surgery. Comparisons between groups were performed by chi-squared test. RESULTS: Recurrence involved the rectal wall in 26 patients (90 percent) and was purely extrarectal in only 3 (10 percent). Mean time between local excision and radical operation was 26 months. The resection was considered curative in 23 patients (79 percent). The stage of the recurrent tumor was more advanced than the primary tumor in 27 patients (93 percent). At a mean follow-up of 39 (range, 2-147) months after radical surgery, 17 patients (59 percent) remained free of disease. The disease-free survival rate was 68 percent for patients with tumors with favorable histology vs. 29 percent for patients with tumors with unfavorable histology. CONCLUSION: Salvage surgery for recurrence after local excision of rectal cancers may not provide results equivalent to those of initial radical treatment. In the present study the poor results of salvage surgery emphasize the importance of appropriate selection of the initial treatment of Stage I rectal cancer.     

Effect of Anastomosis Level on Continence Performance and Quality of Life after Colonic J-pouch Reconstruction

Total mesorectal excision (TME) has become the recommended method for treatment of cancer in the middle or lower third of the rectum. Thus very low anastomoses are necessary to preserve continence, and pouch reconstruction is favored. It is unclear whether the level of anastomosis is important for continence and quality of life in colonic J-pouch reconstruction. In this investigation all patients were included who underwent curative elective anterior continuity resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 2001 and December 2004. Exclusion criteria were distant metastases and any signs of recurrence at the time of investigation. Evaluation of continence performance by Wexner and Holschneider questionnaire and quality of life using the QLQ-C30 and QLQ-CR38 (EORTC) questionnaires was done 220 ± 38 days after closure of the protective Ileostomy, which was performed 106 ± 48 days after primary intervention. Fifty-two patients (79%) were analyzed. Colopouch rectal anastomosis was performed in eighteen cases and colopouch anal anastomosis in thirty-four cases. Fifty percent of the patients in both groups were continent for solid stool. Patients with a colopouch anal anastomosis had a significantly higher rate of incontinence for liquid stool, however. They took stool-regulating medicine more frequently and complained of fecal soiling and a restricted quality of life. Patients with a colopouch anal anastomosis had a significantly lower score on the most important points of the QLQ-C30 (emotional functioning, social functioning, pain, and quality of life). The same applied to the QLQ-CR38 for body image and problems with defecation. The quality of life of patients with a colopouch anal anastomosis was still considered acceptable compared with reference data for the normal healthy population, however. Both continence and quality of life are substantially affected by the level of the anastomosis after colonic pouch reconstruction. This suggests preservation of a small part of the rectum when oncologically feasible and performing a colopouch rectal anastomosis.     

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994–2003

Background and aims This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution.Patients and methods One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures.Results The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5–100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006).Conclusion With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.     

Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer

AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CM) in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CM in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vsthe straight CM. METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales]. RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown. Furthermore, we found that FISI scores highly correlated with FIQL scales. CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE for low-lying rectal cancer.     

Local tumor recurrence after curative resection for rectal cancer

Local tumor recurrence rates after curative rectal cancer surgery with the end-to-end anastomosis stapler (EEA^®) are reportedly high. Therefore, a retrospective review in ten Yale-affiliated hospitals was undertaken to establish the outcome of surgical resection for rectal cancer in this patient population. Of those 373 patients who had had curative resections, 192 (52 percent) were abdominoperineal resections (APR); 105 patients (28 percent) had restorative resections with sutured anastomoses, and the EEA stapler was used in 76 patients (20 percent). There was an equal distribution of tumors in the various Dukes' stages in all three procedures. Local tumor recurrence was: APR 19 percent, SUT 17 percent, and EEA 24 percent, but local tumor recurrence was more frequent after EEA than APR for tumors 7 to 10 cm from the anal verge (32 vs. 13 percent, respectively,P<0.05), and the time to recurrence was least in EEA patients. It is concluded that local tumor recurrence is higher than expected for all three procedures and that the EEA stapler was associated with a greater risk of local tumor recurrence. These findings are attributed to surgeon-related technical operative factors rather than to the nature of the tumors themselves.     

Adenocarcinoma below ileoanal anastomosis for ulcerative colitis: report of a case and review of the literature

BACKGROUND: Restorative proctocolectomy with hand-sewn ileoanal anastomosis and mucosectomy is warranted in patients with dysplasia and/or cancer on ulcerative colitis to prevent subsequent neoplastic changes in the retained mucosa. However, complete excision of the colonic mucosa cannot be obtained reliably. We report a case of anal canal adenocarcinoma after handsewn anastomosis with mucosectomy. METHODS: A 47-year-old patient, previously submitted to ileorectal anastomosis for colonic cancer on ulcerative colitis, underwent completion proctectomy and handsewn ileoanal anastomosis with mucosectomy for recurrent anastomotic cancer. Two years later, we submitted the patient to pouch removal with permanent ileostomy for a mucinous adenocarcinoma of the anal canal (T2N2Mx) found at follow-up pouch endoscopy. CONCLUSIONS: Only four cases of adenocarcinoma after handsewn anastomosis have been reported in the literature. This new case we report confirms that the risk of malignancy after ileoanal anastomosis with mucosectomy, although small, is real, despite the surgeon taking care with this particular step of the procedure. Careful surveillance is needed in patients with surgical treatment for long-term ulcerative colitis or dysplasia.     

Is local excision adequate therapy for early rectal cancer?

PURPOSE: Radical surgery of rectal cancer is associated with significant morbidity, and some patients with low-lying lesions must accept a permanent colostomy. Several studies have suggested satisfactory tumor control after local excision of early rectal cancer. The purpose of this study was to compare recurrence and survival rates after treating early rectal cancers with local excision and radical surgery. METHODS: One hundred eight patients with T1 and T2 rectal adenocarcinomas treated by transanal excision were compared with 153 patients with T1N0 and T2N0 rectal adenocarcinomas treated with radical surgery. Neither group received adjuvant chemoradiation. Mean follow-up time was 4.4 years after local excision and 4.8 years after radical surgery. RESULTS: The estimated five-year local recurrence rate was 28 percent (18 percent for T1 tumors and 47 percent for T2 tumors) after local excision and 4 percent (none for T1 tumors and 6 percent for T2 tumors) after radical surgery. Overall recurrence was also higher after local excision (21 percent for T1 tumors and 47 percent for T2 tumors) than after radical surgery (9 percent for T1 tumors and 16 percent for T2 tumors). Twenty-four of 27 patients with recurrence after local excision underwent salvage surgery. The estimated five-year overall survival rate was 69 percent after local excision (72 percent for T1 tumors and 65 percent after T2 tumors) and 82 percent after radical surgery (80 percent for T1 tumors and 81 percent for T2 tumors). Differences in survival rate between local excision and radical surgery were statistically significant in patients with T2 tumors. CONCLUSIONS: Local excision of early rectal cancer carries a high risk of local recurrence. Salvage surgery is possible in most patients with local recurrence, but may be effective only in patients with T1 tumors. When compared with radical surgery, local excision may compromise overall survival in patients with T2 rectal cancers.Supported by Minnesota Colon and Rectal Foundation and TUMORS database.Read at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Rectal cancer surgery with sphincter preservation: functional results related to the level of anastomosis. Clinical and instrumental study

BACKGROUND/AIMS: Unsatisfactory functional results have been reported not only after coloanal anastomosis, but also after anterior resection with colorectal anastomosis. The aim of this study is to establish functional outcome predictive factors related to surgical technique and especially the real impact of residual rectum length to identify patients who could benefit from colonic pouch reconstruction. METHODOLOGY: Sphincter preservation was achieved in 214 of 327 patients who underwent surgery for rectal cancer. Patients have been subdivided according to the level of anastomosis measured by a rigid proctoscope from the anal verge. In 93 patients functional results have been assessed by clinical control and anorectal manometry. RESULTS: Functional alterations such as leakage (13%), incontinence (5%), urgency (5%) and difficulty in evacuation (10%) appeared in patients who underwent anterior resection with anastomosis 4 to 6 cm from the anal verge. Nevertheless, comparing anterior resection with anastomosis 6 to 8 cm and that with anastomosis 4 to 6 cm rectal compliance was the only parameter whose difference is statistically significant. CONCLUSIONS: This result makes us to believe that patients who undergo anterior resection with no more than 2-3 cm of residual rectum could benefit from a colonic pouch reconstruction.     

Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

PURPOSE Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.METHODS All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.RESULTS Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39–43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2–90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.CONCLUSIONS Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 7, 2002.     

Colonic Surgery in Patients With Juvenile Polyposis Syndrome: A Case Series

PURPOSE Juvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps.METHODS The charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients current status.RESULTS There were 13 patients (6 males) with a median age of 10 years (range, 1–50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6–34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch–anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2–24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch.CONCLUSIONS One-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.     

Neoadjuvant Chemoradiation Increases the Risk of Pelvic Sepsis After Radical Excision of Rectal Cancer

PURPOSE This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer. METHODS A retrospective chart review was conducted for all patients who underwent curative mesorectal excision for rectal cancer during an eight-year period. Demographic, preoperative, perioperative data were collected. Pelvic sepsis was defined as clinical or radiographically demonstrable leak or a pelvic abscess. Neoadjuvant chemoradiation included 5,040 Gy in conjunction with three cycles of 5-fluorouracil-based chemotherapy, followed by a one-month waiting period. RESULTS From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36–97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann’s. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis ≤6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis ≥7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3–9). CONCLUSIONS The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients. Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. Reprints are not available.     

Analysis of recurrence following curative low anterior resection and stapled anastomoses for carcinoma of the middle third and lower rectum

In a series of 93 patients with middle and lower rectal cancer, who underwent potentially curative surgery by low anterior resection (LAR) with EEA stapled anastomosis or by abdominoperineal excision (APE) between January 1977 and December 1981, the incidence of recurrence and survival rate was compared. LAR with stapler was performed in 61 patients: 55 (90.2 percent) with tumors of the middle third and six (9.8 percent) for tumors of the lower third of the rectum. APE was performed in 32 patients: 13 (40.6 percent) with cancer of the midrectum and 19 (59.4 percent) of the lower rectum. Tumor site, Dukes' distribution, grade of malignancy, and extent of local spread were recorded. The tumor stages for LAR with stapler and for APE, respectively, were Dukes' A 7/1; Dukes' B 27/10; Dukes' C 25/18; Dukers' D 2/3. In a follow-up period of four years (range, 6 to 52 months) the overall recurrence rates were 20.4 percent in the LAR with stapled anastomosis group and 21 percent in the APE group. Local recurrence percentages were 9.8 percent after LAR and 14 percent after APE (P=N.S.). Distant recurrences were 12 percent and 14 percent, respectively. The four-year overall survival rates were 76.7 percent after factors correlated with recurrence in low rectal carcinoma were reanalyzed and the controversial points of the surgical management for and against LAR with stapled anastomosis and APE were discussed. It is concluded that LAR with the EEA stapler can be carried out in the middle and lower rectum with the prospect of ultiate cure when performed with proper technical skills in selected patients. Read in part at the meeting of the American Society of Colon and Rectal Surgeons, Houston. Texas, May 11 to 15, 1986.     

The influence of type of operation for distal rectal cancer: survival, outcomes, and recurrence

BACKGROUND/AIMS: This study analyzed the results of treatment of rectal cancer (tumor within 12 cm of the anal verge) with different techniques. METHODOLOGY: Two hundred and sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12cm of the anal verge were evaluated. The operative data and follow-up data were collected prospectively. Comparisons were made between patients who had different surgical procedures. RESULTS: The overall peroperative mortality rate was nil, and the morbidity 39.4%. Local recurrence occurred in 21 of the patients with a median follow-up of 34 months (range: 5-105 months). The 3-year actuarial local recurrence rates for double-stapled anastomosis, low straight anastomosis and APR were 25%, 6%, and 5%, respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (p = 0.013). On multivariate analysis reconstruction with Knight-Griffen anastomosis (p = 0.013) and tumor distance from the anal verge <6 cm (p = 0.001), were associated with local recurrence but only stage was a significant prognosticator of overall survival (p = 0.012). CONCLUSIONS: Following total mesorectal excision, the local recurrence rate was higher in patients treated with double-stapled low anterior resection than in those with termino-terminal low anterior resection or APR; survival rates were similar in these groups.     

Preoperative Chemoradiotherapy and Total Mesorectal Excision Surgery for Locally Advanced Rectal Cancer: Correlation With Rectal Cancer Regression Grade

PURPOSE Preoperative long-course chemoradiotherapy is recommended for rectal carcinoma when there is concern that surgery alone may not be curative. Downstaging of the tumor can be measured as rectal cancer regression grade (1-3) and may be of importance when estimating the prognosis. The aim of this study was to look at the long-term results of tumor regression in patients receiving long-course chemotherapy before surgical resection of rectal cancer.METHODS We reviewed those patients who received preoperative chemoradiotherapy followed by surgical resection for carcinoma of the mid rectum or distal rectum found to be stage T3/4 between January 1995 and November 1999. Patients received 45 to 50 Gy irradiation in 2-Gy fractions and an infusion of 5-fluorouracil. Surgical specimens were assessed for rectal cancer regression grade. Patients were followed up routinely with clinical examination, computed tomography, and colonoscopy.RESULTS Sixty-five patients with a mean age 65 (range, 32–83) years underwent chemoradiotherapy before surgical resection. Thirty patients (46 percent) were classified as rectal cancer regression Grade 1, with 9 patients (14 percent) having complete sterilization of the tumor. Fifty-three patients (82 percent) underwent a curative resection. Overall survival, with a median follow-up of 39 (range, 24–83) months, was 67 percent and was associated with tumor downstaging. The local recurrence rate was 5.8 percent in those patients who underwent a curative resection and was significantly lower with rectal cancer regression Grade 1 tumors (P = 0.03). Eight of nine patients (89 percent) whose tumor had been sterilized were alive and well with no recurrence of tumor at a median follow-up of 41 (range, 24–70) months.CONCLUSIONS Preoperative chemoradiotherapy resulted in significant regression of tumor. Overall survival was high and was associated with downstaging of tumor. The local recurrence rate was significantly lower with rectal cancer regression Grade 1 tumors and was not seen in patients with sterilized tumors.Presented at the Association of Coloproctology of Great Britain and Ireland, Manchester, United Kingdom, July 2002.Reprints are not available.