| Abstract: | The aim of surgery in the treatment of malignancies of the rectum is eradication of disease and restoration of the patient to a useful place in society. That this goal is not always achieved is demonstrated by the generally recognized over-all 5-year survival of no more than 45%. Improvement in cure rate rests largely upon early detection of localized disease and new modalities for treatment of disseminated disease, but it is essential to emphasize that an appreciation of current knowledge of anatomy, pathology and physiology and the application of current methods of surgery and rehabilitation will achieve maximum benefit for each patient.Abdominoperineal resection and anterior resection are well-established methods of treatment of carcinoma of the rectum. Study of the spread of cancer and the increasing experience with sphincter-saving operations indicate that sacrifice of the anus is not always essential for the cure of rectal cancer.Our recent experience in treatment of carcinoma of the rectum by abdominosacral, abdominoperineal and anterior resection has been reported.65 Data on sex, age and associated risk and operative motality for this group of 229 patients, treated by one surgeon (SAL), in a 6-year period are summarized in Table 1. The preponderance of males in the abdominoperineal group is not surprising since selection was based on level of lesion, and the wider female pelvis allows sphincter-saving procedures at a lower level. The three groups were otherwise comparable. The status of patients in this series in whom operation was considered curative is recorded in Table 2. A follow-up of up to 8 years shows that survival following abdominosacral resection compares favorably with abdominoperineal and anterior resection. Death from recurrence is correlated, with stage of disease, not with level of lesion.Sphincter function following low anterior resection is essentially normal. Patients are continent of stool and flatus but, as alluded to in the section on continence, they initially experience a period of frequent small bowel movements due to loss of reservoir function. It is gratifying to note that functional results following abdominosacral resection differ only in degree from those observed following standard anterior resection. All patients were continent of stool and flatus from the outset and, after a somewhat longer period, some 12 weeks, of aberrant reservoir continence, all regained satisfactory function. This process of adaptation is facilitated by early institution of a diet high in fiber content and moisture, and encouragement of the patient to suppress the frequent urge to defecate. Patients in this series undergoing abdominosacral resection would under other circumstances have had abdominoperineal resection. A colostomy, even well constructed, properly managed and accepted by the patient, is at best a poor substitute for a functioning anal sphincter.Patients undergoing abdominoperineal resection with permanent sigmoid colostomy are visited by the enterostomal therapist preoperatively. Instruction in colostomy irrigation and management of colostomy appliances begins as soon as intestinal function returns. At discharge on the 14th to 21st postoperative day, patients are confident in colostomy care, and rehabilitation may be continued on an outpatient basis. In 2–3 months 75% of patients achieve sufficient reservoir continence and regularity to spend the day without a colostomy appliance.Unless a patient is moribund from metastatic disease or has serious contraindications to operation due to severe intercurrent illness, an attempt at removal of the lesion should be made in every case. Little can be done to alleviate the suffering due to pain, tenesmus, infection and discharge of blood and mucus from an unresected rectal cancer. Indeed, the apparently inoperable growth may appear fixed because of its bulk rather than by invasion, and the surgical effort is then rewarded by effective palliation or cure. |
