Abdominoperineal resection or low Hartmann's procedure

AIM: To compare patients having low Hartmann's resection (LHP) with abdominoperineal resection (APR) by investigating postoperative complications. METHODS: Retrospective comparative analysis of preoperative state and postoperative course for patients having surgery from 1 January 1997 to 1 July 2001, by the surgeons of the Colorectal Unit, Christchurch Hospital, Christchurch, New Zealand. RESULTS: Over a 54-month period 65 patients underwent either LHP or APR (29 LHP, 36 APR). The median age/sex (male:female) of patients for LHP was 76 years (51-90 years) (14:15), for APR 72 years (31-93 years) (19:17). The indication for surgery was predominantly cancer (LHP 89.6%, APR 94.4%). There was a high rate of preoperative comorbidities: LHP 75.9% (cardiac 62.1%, pulmonary 17.2%), APR 75% (cardiac 50%, pulmonary 15.9%). Preoperative chemoradiation was used in 10.3% of patients having LHP and 30.6% with APR. There was no difference in postoperative non-septic complications. There was a significant difference in the types of septic complications (P = 0.018), with a higher rate of pelvic abscesses after LHP (5). Perineal wound infection occurred in five patients having APR (14.3%). The median time to heal a perineal wound was 1 month (0.5-7 months). The median length of stay was 13 days for LHP (5-33 days) and 11 days for APR (6-19 days) (P = 0.0266). CONCLUSION: This non-randomized, retrospective, cohort study shows a surprisingly high rate of pelvic abscesses after LHP compared with APR. Perineal wound healing was a problem after APR, but less of a management problem than the septic complications after LHP. Both LHP and APR might be associated with significant morbidity. A high pelvic abscess rate following LHP is associated with a high likelihood of further surgical intervention and a prolonged length of stay.     

Electrocoagulation for adenocarcinoma of the low rectum

Cancers of the distal rectum (<7.5 cm from the anal verge) that are freely mobile, moderately well or well differentiated, <4 cm in size, limited to the bowel wall, and without evidence of metastasis should be considered candidates for treatment with electrocoagulation for cure. Tumor cell ploidy and evaluation with intrarectal ultrasound may in the future add additional useful information with regard to patient selection. Electrocoagulation and laser ablation of tumors may also be useful modalities for palliation of patients with metastatic disease or who are not candidates for curative surgery.

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Resumen Casi 50% de los cánceres rectales se ubican a menos de 7.5 cm del borde anal. En general, la sobrevida de los pacientes con cáncer del recto distal ha demostrado ser peor que la de los pacientes con cáncer del colon. Los cánceres del recto distal representan un dilema terapéutico; el estándar de comparación para su tratamiento sigue siendo la resección abdominoperineal descrita por Miles hace más de 80 años. La sobrevida global a 5 años de los pacientes sometidos a resección abdominoperineal es aproximadamente de 50% y poco ha mejorado en los últimos 40 años. La resección abdominoperineal se asocia con mortalidad y morbilidad significativas, especialmente en pacientes mayores de 70 años. Todos los pacientes quedan con colostomía permanente y la mayoría de los hombres resultan impotentes. El advenimiento de nuevas tecnologías y técnicas quirúrgicas ha disminuido la incidencia de resección abdominoperineal para cáncer rectal y, en pacientes seleccionados, el tratamiento local sigue siendo una alternativa viable.Los cánceres del recto distal (por debajo de 7.5 cm del borde anal) que sean móviles, moderadamente o bien diferenciados, con tamaño menor de 4 cm, que estén limitados a la pared y que no presentan evidencia de metástasis, deben ser considerados como candidatos para tratamiento por electrocoagulación con propósito de curación. El estudio de la ploidia tumoral y la evaluación con ultrasonografía intrarectal posiblemente habrán de añadir información útil relativa a la selección de los pacientes. La electrocoagulación y la resección con laser también pueden ser modalidades útiles para la paliación de pacientes con enfermedad metastásica o en aquellos que no son candidatos para cirugía curativa.

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Résumé Les cancers du bas rectum (c'est à dire situés à moins de 7 cm de la marge anale) qui sont mobiles, bien ou assez bien différenciés, de moins de 4 cm de diamètre, limités à la paroi, et sans métastase évidente peuvent être traités par l'électrocoagulation seule. La plodie cellulaire et l'évaluation par l'échographie endorectale sont peut-être de futurs moyens pour sélectionner les patients pouvant être traités ainsi. L'ablation des tumeurs par l'électrocoagulation et le laser sont des méthodes palliatives utiles chez les patients ayant des métastases ou qui ne sont pas des candidats à la chirurgie.

     

Adequate distal margin of resection for adenocarcinoma of the rectum

There are two questions in the surgical treatment of rectal cancer: (1) How far below a palpable rectal cancer should a surgeon cut in order to avoid cutting through cancer and, (2) Given that the surgeon has not cut through cancer, could the chance of subsequent recurrent rectal cancer have been reduced if an even greater length of bowel had been removed. For mobile tumors that are not poorly differentiated the answer to the first question is far enough in order to get a right-angled clamp on below the tumor that will not slip; the answer to the second question is no.     

Abdominoperineal and anterior resection of the rectum with retrocolic omentoplasty and no drainage

Forty consecutive patients scheduled for either low anterior resection or abdominoperineal resection of the rectum have been studied. After standard procedures, carried out by all grades of surgeons, the omentum was mobilized as a pedicle graft based on the left gastro-epiploic arcade and transposed to the pelvis or perineum. All wound were closed primarily without drainage. Twenty-six patients had anterior resection, 11 abdominoperineal resection and 3 an extended Hartmann's operation. Patients were assessed clinically and radiographically by Gastrografin enema and ultrasound for evidence of anastomotic leakage, pelvic collections and wound healing. After anterior resection there were three radiological leaks and no overt clinical leaks. One patient had a collection related to a leak. Of 11 perineal wound 8 healed primarily in 2 weeks and all healed by 4 weeks. There was no frank wound breakdown. The three patients who had Hartmann's operations all healed without complication. There were no unavoidable complications of the procedure. Retrocolic omentoplasty is a simple, safe and effective adjunct to rectal surgery. The additional time taken (15-20 min) is well rewarded by sound healing of these operations.     

Lateral margins of resection in adenocarcinoma of the rectum

Wide dissection of adenocarcinoma of the rectum is difficult because of the fixed structure of the anatomic pelvis. The role of lateral margins, excision of the mesorectum, and extended lymphadenectomy have recently received much attention in the literature in dealing surgically with more advanced rectal carcinomas. The basic question to be resolved in the future is whether additional radical surgery is of more benefit than adjuvant chemoradiation therapy in this setting.

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Resumen La recurrencia local después de resección quirúrgica por adenocarcinoma del recto continúa siendo un problema difícil que encaran los cirujanos. Se ha establecido que hasta la mitad de los pacientes sometidos a resección rectal por cáncer avanzado del recto desarrolla recurrencia local. A diferencia de lo que ocurre con el más móvil colon abdominal, las resecciones amplias de carcinomas ubicados por debajo de la reflexión peritoneal son difíciles debido al confinamiento que presenta la pelvis anatómica. La influencia de los márgenes laterales de la resección, de la resección del mesorecto y de la linfadenectomía amplia han recibido mucha atención en la literatura reciente sobre el manejo quirúrgico de los carcinomas rectales en estado avanzado. El interrogante básico para resolver en el futuro es si en tales circunstancias la cirugía más radical es de mayor beneficio que la terapia adyuvante de quimiorradiación.

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Résumé Faire une résection large d'un cancer du rectum est difficile en raison des structure fixes de la cavité pelvienne. On a beaucoup insisté récemment sur l'importance de la résection large (latérale), l'excision du mésorectum, et la lymphadénectomie dans les cancers du rectum avancés. La question de base est de savoir si la chirurgie radicale est plus bénéfique que la chimiothérapie dans cette circonstance.

     

Aspects of low anterior rectum resection

Results analysis of 162 low anterior rectum resections, carried out in the hospital during 1999-2006 years on account of upper and medial rectal ampulla adenocarcinoma is presented in the article. Method of marking rectum resection distal border with use of optical coherent tomography was worked out and put into practice. Comparative evaluation of operation results with total and partial mesorectal cellular tissue removal was carried out. It is established that local recurrence has been indexed in 14.28% of patients undergoing anterior resection with maintenance of mesorectum part in 7.89% of patients undergoing mesorectumectomy. Indications for mobilization of left bend colon and one or another type of discharge ostomy were formulated. Measures for prediction and prophylaxis of anal incontinence after rectum resection and also the new method of small pelvis cavity intraoperative drainage were offered.     

Pelvic and perineal recurrences after abdominoperineal resection for adenocarcinoma of the rectum

Pelvic and perineal recurrences were evaluated in 48 patients who underwent abdominoperineal resection at Roswell Park Memorial Institute for adenocarcinoma of the rectum. The duration of follow-up of these patients was at least 5 years or until death. There were 26 male and 22 female patients with a median age of 60 years. In 40 patients, the abdominoperineal resection was considered to be curative and in the remaining 8 patients, palliative abdominoperineal resection was performed. Only 2 of the 48 patients had a pelvic recurrence and in none of these patients was this recurrence the first site of relapse. One of the 48 patients had a local perineal recurrence; however, this was treated successfully with surgery. This represents a total of three pelvic or perineal recurrences in 48 patients, for a recurrence rate of 6 percent.     

Laparoscopic-assisted abdominoperineal resection for low rectal adenocarcinoma

BACKGROUND: Laparoscopic-assisted resection for colorectal lesions is feasible, but most reported series are heterogeneous and noncomparative. The aim of this study was to investigate whether laparoscopic-assisted resection was better than open abdominoperineal resection for low rectal adenocarcinoma. METHODS: Twenty-five (study group) of 59 consecutive patients who were considered suitable were selected for laparoscopic-assisted abdominoperineal resection based on the availability of informed consent, laparoscopic instruments, and experienced surgeons. The results in these patients were compared with the other 34 patients operated on by the open method (control group). RESULTS: The median follow-up times for the study and control groups were 30.1 and 28.3 months, respectively. The operation time was significantly longer (t-test, p < 0.001), while operative blood loss (Mann-Whitney U test, p = 0.02), postoperative analgesic requirement (Mann-Whitney U test, p = 0.02), time to resume normal diet (Mann-Whitney U test, p = 0.04), and total hospital stay (Mann-Whitney U test, p = 0.02) were significantly less in the study than in the control group. The oncological clearance, complication rate, disease-free interval, and survival were comparable in the two groups. CONCLUSIONS: Laparoscopic-assisted abdominoperineal resection allowed earlier postoperative recovery, with equal oncological clearance, morbidity, mortality, disease-free interval, and survival.     

Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum

The results of rectal excision with colonic pouch-anal anastomosis are reviewed from a series of 162 patients covering 7 years. All patients have been operated upon in the same institution and consecutively. The follow-up is now sufficient to allow an accurate evaluation of the outcome of the patients. The main goal of this study was to provide a detailed report of the functional results. Continence was satisfactory in 96% of the patients, with either a perfect continence or minor troubles that would not have been detectable other than by a rigorous questioning. The mean number of bowel movements was 2 per 24 hours. Fragmentation of the defecation and urgency were absent. Twenty-five per cent of the patients had to elicit the evacuation of the reservoir with a suppository or an enema. Improvement of function yielded by a reservoir over straight colo-anal and low colo-rectal anastomoses are significant and, as suggested by manometric studies, are directly related to the restoration of a reservoir function.

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Resumen Se revisan los resultados de la resección rectal con anastomosis colónica a bolsa anal en una serie de 162 pacientes en el curso de siete años. Todos los pacientes fueron operados en la misma institución y en forma consecutiva. El período de seguimiento ya es suficiente para permitir una evaluación certera de los resultados en tales pacientes. El propósito principal de este estudio fué el de proveer un reporte detallado de los resultados funcionales. La continencia anal apareció satisfactoria en 96% de los pacientes, con continencia perfecta o con problemas menores que no habrían sido detectables sino bajo interrogatorio riguroso. El número promedio de defecaciones fué de 2/24 horas. No se observaron fragmentación de la defecación ni sensación de urgencia. Veinticinco por ciento de los pacientes tuvo que provocar la evacuación del reservorio mediante un supositorio o un enema. Es significativa la mejoría de la función que provee un reservorio en comparación con la anastomosis directa colo-anal o con las anastomosis colo-rectales bajas, y según lo sugieren estudios manométricos está directamente relacionada con la restauración de función de reservorio.

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Résumé Les résultats fonctionnels d'une série de 162 patients consécutifs, opérés pour cancer rectal dans le même service pendant une période de 7 ans, sont présentés. Tous ces patients ont eu une résection rectale suivie d'une anastomose coloanale avec résevoir. La continence était jugée satisfaisante (continence parfaite ou troubles mineurs passant inapercus en dehors d'un interrogatoire poussé) chez 96% des patients. Le nombre moyen de selles par 24 heures était de deux. Aucun patient ne s'est plaint de fragmentation de selles ou de besoins impérieux. Vingt pour-cent des patients éprouvaient le besoin de provoquer l'évacuation de leur résevoir soit par un suppositoire, soit par un lavement. L'amélioration de la continence par l'anastomose colo-anale avec résevoir, par rapport à l'anastomose colo-anale sans résevoir ou par rapport à une anastomose colorectale basse, est nette et semble être directement en rapport avec la création de ce résevoir.

     

Sphincter function after low anterior resection of the rectum

Until a few years ago, surgical technique and the age-old convictions of oncological radicality rejected very low rectal resections for cancer, particularly as the problem of postoperative incontinence did not exist. Currently, on the other hand, with the advent of mechanical staplers, the surgeon attempts increasingly to reconcile the possibility of using new sphincter-saving techniques with adequate oncological radicality, backed by accurate pre- and intraoperative staging. It is underlined that postoperative assessment of sphincter function in all its aspects, both clinical and instrumental, may be useful for the purpose of clarifying what anatomical structures should really be saved, delegated to retaining sphincter sensitivity and reflexes, so improving the functional results of operations. In addition, the almost rare identification of manifest or latent postoperative incontinence would make it possible to intervene in operated patients, for example by functional reeducation techniques as happens in the relatively recent biofeedback techniques.     

Anastomotic dehiscence after low anterior resection of the rectum

Thirty-two patients who had anastomoses to the extraperitoneal rectum underwent radiographic contrast studies about two weeks after operation in order to determine the incidence of anastomotic dehiscence. No extravasation occurred in the sixteen anastomoses in which the middle hemorrhoidal arteries were intact, but partial disruption occurred in four of seventeen (24%) anastomoses in which the middle hemorrhoidal arteries were sacrificed. Since not all patients with anastomotic dehiscence after low anterior resection are symptomatic, the incidence of anastomotic breakdown will be under-estimated unless x-ray studies are performed. More data are required for a better understanding of the technical features of operation which will reduce the incidence of leakage from anastomoses to the extraperitoneal rectum.     

低位前切除术与腹会阴联合切除术治疗中低位直肠癌

目的探讨在中低位直肠癌的外科治疗中，低位前切除术与腹会阴联合切除术对预后的影响。方法对1995年6月至1999年12月间收治的中低位（肿瘤下缘距肛缘〈8cm）直肠癌283例的临床资料进行回顾性分析。其中低位前切除（low anterior resection，LAR）组181例，腹会阴联合切除术（abdominoperineal resection，APR）组102例。结果Logistic回归分析显示肿瘤分期和细胞分化程度是直肠癌的独立预后因素（P〈0．05），而性别、年龄、身高体重指数和手术方式均与预后无明显相关性（P〉0．05）。按照手术方式分为LAR组和APR组，用精确概率法对两组患者的分期和细胞分化程度的差异进行卡方检验，两组患者的预后差异无统计学意义（P〉0．05）。结论中低位直肠癌外科治疗中，LAR和APR手术方式对直肠癌的预后没有明显影响。     

低位直肠癌腹腔镜辅助下腹会阴联合切除术

目的评估低位直肠癌的腹腔镜辅助下手术是否优于传统的腹会阴联合切除术。方法研究组在５９例连续入院的患者中选择２４例进行腹腔镜辅助下腹会阴联合切除术,研究组与其他３４例用传统方法手术的患者（对照组）进行比较。结果研究组和对照组分别随访３０．１个月和２８．３个月。研究组较对照组手术时间明显延长（Ｐ＜０．００１）,而术中出血量（Ｐ＝０．０２）和术后镇痛剂的需要量（Ｐ＝０．０２）明显少于对照组,恢复正常饮食的时间（Ｐ＝０．０４）和总住院时间（Ｐ＝０．０２）明显短于对照组。两组的肿瘤清除情况、并发症发生率、无瘤间期和生存率无明显差别。结论腹腔镜辅助下腹会阴联合切除术与传统手术比较术后恢复较快,而肿瘤清除情况、并发症、病死率、无瘤间期以及生存率无明显差别。     

Function of the distal rectum after low anterior resection for carcinoma.

From a personal series of 232 anterior resections performed over 10 years, functional results have been analysed in two specific groups of patients: those with anastomoses 3 cm (n = 26) and 6 cm (n = 42) from the anal verge. In both groups low anterior resection had been performed with total mesorectal excision. Function was assessed in four categories: bowel frequency, ability to distinguish flatus from faeces, ability to defer defaecation, and frequency of soiling. Independent analysis of the 3 cm group showed a significant deterioration in function in each category after operation. The ability to defer defaecation and the frequency of soiling were unchanged after operation in the 6 cm group, and these functions were significantly better than in the 3 cm group. On the basis of these results, patients undergoing low anterior resection with total mesorectal excision should benefit from the preservation of a short segment of distal rectum, provided that the distal resection margin is not compromised.