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Benefit of rectal washout for anterior resection and left sided resections
International Journal of Surgery 25 (2016) 106e108
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Best Evidence Topic
Benefit of rectal washout for anterior resection and left sided resections Najaf Siddiqi, Muhammad Abbas*, Zafar Iqbal, Muhammad Farooq, John Conti 1, Amjad Parvaiz 1 Queen Alexandra Hospital, Portsmouth, United Kingdom
h i g h l i g h t s No randomized study has been undertaken on this subject and almost all the studies favoured a randomized control trial. Rectal washout does not stop local recurrence of cancer, but it may reduce the rate of local recurrence. A randomised controlled trial including surgical techniques utilised in recent years would formally answer the question.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 June 2015 Accepted 24 November 2015 Available online 25 November 2015
Purpose: To assess the effectiveness of rectal wash out in preventing local recurrence for patients who undergo anterior resection for recto-sigmoid cancer. Materials and methods: A best evidence topic was constructed according to a structured protocol. Medline 1948e2015 and EMBASE 1980 to 2015 using the OVID interface: ( Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched. Outcomes: Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 metaanalyses. Conclusions: On the basis of current evidence, rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to address this issue would formally answer this question. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Keywords: Rectal washout Anterior resection Left sided-resections
1. Introduction
3. Search strategy
A best evidence topic was constructed according to a structured protocol. This is fully described in a previous publication in the IJS [1].
Medline 1948e2015 and EMBASE 1980 to 2015 using the OVID interface: (Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched.
2. Three part question Is Rectal Washout effective for preventing local recurrence in patients who undergo an anterior resection for carcinoma of the rectum or sigmoid?
* Corresponding author. 1 Joint Senior authors.
4. Search outcome 41 papers were found using the reported search. After removing the duplicates, there were 24 articles. Out of 24, only 17 relevant articles were found. Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 meta-analyses. Best evidence papers are shown in Table 1.
http://dx.doi.org/10.1016/j.ijsu.2015.11.041 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
N. Siddiqi et al. / International Journal of Surgery 25 (2016) 106e108
107
Table 1 Best evidence papers. Author, year & country Study type
C. Zhou et al., 2014, China [18]
Wash-out Level of Total evidence number of (n)/Local recurrence patients (%)
Statistical No rectal significance wash-out (n)/Local recurrence (%)
Comments Median follow-up after resection (Months)
Meta-analysis Level II
5519
4176/5.75% 1343/9.75%
Yes
NS
A. Matsuda et al., 2012, Meta-analysis Level II US [21]
5395
4121/5.79% 1274/10.05%
Yes
NS
F. Rondelli et al., 2012, Meta-analysis Level II UK [20] K. Kodeda et al., 2010, PNR Level III UK [6]
5024
3927/5.9%
1097/10.2%
Yes
33
4600
3749/6%
851/10.2%
Yes
60
Constantinides et al., 2008 Germany [12]
Meta-analysis Level II
432
176/4.8%
256/10.2%
No
NS
Terzi et al., 2006, Switzer-land [16]
PNR study
Level III
96
38/8%
58/3.4%
No
23
Agaba et al., 2004, Germany [11] Long et al., 1989, US [15]
RNR study
Level III
141
90/4.4%
51/5.9%
No
63
PNR study
Level III
185
40/2.6%
145/14.3%
Yes
60
Favours rectal wash out but mentions that there is no stable evidence to confirm the efficacy of rectal WO for RR or TME. Favours normal saline (500e2000 ml) over other solutions. 3 times more patients in the washout group. Favours rectal washout but different washouts and volumes utilized. 3.5 times more patients in washout group. Only 3 studies standardized TME used. 3 out of 9 studies included non-curative resections. Favours rectal washout but different washouts and volumes utilized. Favours rectal washout Looked at outcomes from the Swedish registry. 4 times more patients in the washout group Statistically not significant. Same trials included as Rondelli et al. [20], but does not include the Kodeda et al. [6] study Unequal groups. Recurrence higher in those who had washout Small sample size and follow-up duration Unequal groups Small sample size Very few in the washout group Small sample size
Abbreviations: PNR ¼ Prospective non randomized, RNR ¼ Retrospective non randomized, NS ¼ Not stated, WO ¼ Wash out, RR ¼ Radical resection, TME ¼ Total mesorectal excision.
5. Discussion Intraoperative rectal washout is performed to prevent postoperative infection and local cancer recurrence. Lloyd Davis may have been the first to perform rectal washout to prevent cancer recurrence. In 1948 he reported “Especial care must be taken to avoid implanting cancer cells”. Although there is difference in opinion on the benefit of rectal washout by different study groups, most colorectal surgeons still prefer rectal washout during anterior resection and left sided resections. Local recurrence after rectal cancer surgery may be avoided if no viable tumour cells are left behind. Colorectal tumours shed viable cells into the bowel lumen [2e4] and there is convincing evidence that these cells can deposit and increase the chances of local recurrence [2,5e8]. Rectal washout with cytotoxic agent was introduced to reduce the amount of free malignant cells. Rectal washout consists of cross clamping the rectum, distal to the tumour but proximal to the intended line of transection, followed by irrigation of the lumen from the anus to the clamp. Different types of solutions have been used, and their cytocidal effects have been studied in vitro and in vivo with conflicting results [9,10]. The overall rate of local recurrence varies from 5% to 15% according to different studies [11,12]. Church et al., stated that it is a mechanical cleansing effect of the solution rather than cytocidal effect and recommended intra-operative saline rectal washout before anastomosis [13]. Few studies have looked at the quantity of solution used for washout, but Maeda et al. suggested that more proximal tumours need a large volume of irrigation fluid [14]. Many studies have suggested different washout solutions (iodine-povidone, cetrimide, normal saline and formalin) but there is no statistical difference between whichever one is used. Long et al. [15] demonstrated a benefit in terms of local recurrence using a washout with 1% formalin solution, by contrast Terzi et al. [16] showed local recurrence rates were higher when utilising
a washout with povidone e iodine solution. They also found no difference in the presence of viable tumour cells in the staple guns with or without a washout [15,16]. Dehni et al. utilising a 5% povidone iodine solution demonstrated low recurrence rates after rectal washout [17] and Agaba et al. [11] found no benefit in terms of local recurrence using a cetrimide rectal washout. A recent meta-analysis by Zhou et al. favoured rectal wash out to reduce the incidence of local recurrence but mentioned that there was no stable evidence to confirm the efficacy of rectal wash to be practiced routinely for radical resection or total mesenteric excision and favoured saline (500e2000 ml) over other solutions [18]. Their study had 3 times more patients in the washout group and the selection criteria involved studies with no minimum trial duration including retrospective case series [18]. Another recent case control study by Xingmao et al. reviewed data of 144 patients with rectal cancer undergoing anterior resection [19]. The rectal wash out group (n ¼ 69, 1500 ml physiological saline) and the non-washout group (n ¼ 75) found no statistically significant difference (p ¼ 0.721) between the two regarding local recurrence of rectal cancer during a median follow-up of 48 month. One of the reservations regarding this study is a smaller sample size with a shorter duration of post-operative follow-up. The authors mentioned that and recommended a large-scale research with a longer follow-up [19]. A meta-analysis by Rondelli et al. strongly recommended rectal washout [20]. However the amount and type of fluid varied significantly among studies included within their analysis and so did the follow-up and hence caution is advised regarding making firm recommendations based upon their study [20]. A meta-analysis by Matsuda et al. [21], suggested that in rectal cancer there was a significant reduction in local recurrence rate using rectal washout, utilising 5 of the same studies as used by Rondelli et al. [20], but accepted that in only 3 of these studies, total
108
N. Siddiqi et al. / International Journal of Surgery 25 (2016) 106e108
mesorectal excision (TME) was utilised as the surgical technique in rectal cancer resection and in one-third (3 out of 9) of these studies, patients undergoing non-curative resections were included in the results. A study by Kodeda et al. demonstrated no statistical difference in local recurrence between the two groups but it favoured rectal washout as these patients had less local recurrence. [6] There was a good pattern of follow-up but the data was obtained from patients enrolled on the Swedish cancer registry and was more of a prospective non-randomised study and there was a bias towards rectal washout in terms of recruitment to the study [6]. Constantinides et al. recommended rectal washout after comparing 5 studies; using different solutions (cetrimide, povidone-iodine, 1% formalin and normal saline), but the differences identified were not significant [12]. No randomized study has been undertaken on this subject and almost all the studies have favoured a randomized control trial (RCT), although Kodeda et al. felt such study would need 1400 patients and a five-year follow-up which would be impractical [6]. However, with the increasing use of laparoscopic surgery, cross clamping can be technically difficult. Additionally, in all cases now, a TME rectal dissection technique is employed, which has been shown to reduce local recurrence rates [22]. Many laparoscopic surgeons do not routinely employ rectal washout so we feel it would be beneficial if we finally address this question, particularly taking into account the changes in surgical techniques employed. 6. Clinical bottom line Rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to formally address this issue, particularly taking into account the changes in surgical technique utilised in recent years would formally answer this question. 7. Conflicts of interest None. 8. Sources of funding None. 9. Ethical approval None. 10. Author contribution Dr. Dr. Dr. Dr.
Najaf Siddiqi-writing. Muhammad Abbas-writing. Zafar Iqbal-writing. Muhammad Farooq-writing.
Dr. John Conti- Conception of idea. Professor Amjad Parvaiz- Conception of idea and supervision. 11. Guarantor Professor Dr. Amjad Parvaiz. References [1] O.A. Khan, J. Dunning, A.C. Parvaiz, R. Agha, D. Rosin, K. Mackway-Jones, Towards evidence-based medicine in surgical practice: best BETs, Int. J. Surg. 9 (2011) 585e588. [2] D. Skipper, A.J. Cooper, J.E. Marston, I. Taylor, Exfoliated cells and in vitro growth in colorectal cancer, Br. J. Surg. 74 (1987) 1049e1052. [3] A.N. Rygick, S.N. Fain, G.N. Pestovskaja, Viability of cancer cells penetrating tissues during operations for cancer of the rectum, Dis. Colon Rectum 12 (1969) 351e356. [4] H.C. Umpleby, B. Fermor, M.O. Symes, R.C. Williamson, Viability of exfoliated colorectal carcinoma cells, Br. J. Surg. 71 (1984) 659e663. [5] M.O. Symes, B. Fermor, H.C. Umpleby, C.R. Tribe, R.C. Williamson, Cells exfoliated from colorectal cancers can proliferate in immune deprived mice, Br. J. Cancer 50 (1984) 423e425. [6] K. Kodeda, E. Holmberg, F. Jorgren, S. Nordgren, G. Lindmark, Rectal washout and local recurrence of cancer after anterior resection, Br. J. Surg. 97 (2010) 1589e1597. [7] H.C. Umpleby, R.C. Williamson, Anastomotic recurrence in large bowel cancer, Br. J. Surg. 74 (1987) 873e878. [8] A. Tsunoda, M. Shibusawa, Y. Tsunoda, H. Choh, M. Takata, M. Kusano, Implantation on the suture material and efficacy of povidone-iodine solution, Eur. Surg. Res. 29 (1997) 473e480. [9] H.C. Umpleby, R.C. Williamson, The efficacy of agents employed to prevent anastomotic recurrence in colorectal carcinoma, Ann. R. Coll. Surg. Engl. 66 (1984) 192e194. [10] J.G. Docherty, J.R. McGregor, C.A. Purdie, D.J. Galloway, P.J. O'Dwyer, Efficacy of tumoricidal agents in vitro and in vivo, Br. J. Surg. 82 (1995) 1050e1052. [11] E.A. Agaba, Does rectal washout during anterior resection prevent local tumor recurrence? Dis. Colon Rectum 47 (2004) 291e296. [12] V.A. Constantinides, D. Cheetham, R.J. Nicholls, P.P. Tekkis, Is rectal washout effective for preventing localized recurrence after anterior resection for rectal cancer? Dis. Colon Rectum 51 (2008) 1339e1344. [13] J.M. Church, P. Gibbs, M.W. Chao, J.J. Tjandra, Optimizing the outcome for patients with rectal cancer, Dis. Colon Rectum 46 (2003) 389e402. [14] K. Maeda, M. Maruta, T. Hanai, H. Sato, Y. Horibe, Irrigation volume determines the efficacy of 'rectal washout', Dis. Colon Rectum 47 (2004) 1706e1710. [15] R.T. Long, R.H. Edwards, Implantation metastasis as a cause of local recurrence of colorectal carcinoma, Am. J. Surg. 157 (1989) 194e201. [16] C. Terzi, T. Unek, O. Sagol, T. Yilmaz, M. Fuzun, S. Sokmen, et al., Is rectal washout necessary in anterior resection for rectal cancer? A prospective clinical study, World J. Surg. 30 (2006) 233e241. [17] N. Dehni, S. Caplin, P. Frileux, R. Sarkis, R. Parc, Cancer recurrence along the pouch longitudinal suture line after colonic J pouch-anal anastomosis, Br. J. Surg. 89 (2002) 206e207. [18] C. Zhou, Y. Ren, J. Li, X. Li, J. He, P. Liu, Systematic review and meta-analysis of rectal washout on risk of local recurrence for rectal cancer, J. Surg. Res. 189 (2014) 7e16. [19] Z. Xingmao, B. Jianjun, W. Zheng, L. Jianwei, H. Junjie, Z. Zhixiang, Analysis of outcome of intra-operative rectal washout in patients with rectal cancer during anterior resection, Med. Oncol. 30 (1) (2013 Mar) 386, http:// dx.doi.org/10.1007/s12032-012-0386-6. Epub 2013 Jan 4. [20] F. Rondelli, S. Trastulli, R. Cirocchi, N. Avenia, E. Mariani, F. Sciannameo, et al., Rectal washout and local recurrence in rectal resection for cancer: a metaanalysis, Colorectal Dis. 14 (2012) 1313e1321. [21] A. Matsuda, T. Kishi, G. Musso, T. Matsutani, K. Yokoi, P. Wang, et al., The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis, Ann. Surg. Oncol. 20 (2013) 856e863. [22] R.J. Heald, R.D. Ryall, Recurrence and survival after total mesorectal excision for rectal cancer, Lancet 28 (1986) 1479e1482.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Best Evidence Topic
Benefit of rectal washout for anterior resection and left sided resections Najaf Siddiqi, Muhammad Abbas*, Zafar Iqbal, Muhammad Farooq, John Conti 1, Amjad Parvaiz 1 Queen Alexandra Hospital, Portsmouth, United Kingdom
h i g h l i g h t s No randomized study has been undertaken on this subject and almost all the studies favoured a randomized control trial. Rectal washout does not stop local recurrence of cancer, but it may reduce the rate of local recurrence. A randomised controlled trial including surgical techniques utilised in recent years would formally answer the question.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 June 2015 Accepted 24 November 2015 Available online 25 November 2015
Purpose: To assess the effectiveness of rectal wash out in preventing local recurrence for patients who undergo anterior resection for recto-sigmoid cancer. Materials and methods: A best evidence topic was constructed according to a structured protocol. Medline 1948e2015 and EMBASE 1980 to 2015 using the OVID interface: ( Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched. Outcomes: Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 metaanalyses. Conclusions: On the basis of current evidence, rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to address this issue would formally answer this question. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Keywords: Rectal washout Anterior resection Left sided-resections
1. Introduction
3. Search strategy
A best evidence topic was constructed according to a structured protocol. This is fully described in a previous publication in the IJS [1].
Medline 1948e2015 and EMBASE 1980 to 2015 using the OVID interface: (Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched.
2. Three part question Is Rectal Washout effective for preventing local recurrence in patients who undergo an anterior resection for carcinoma of the rectum or sigmoid?
* Corresponding author. 1 Joint Senior authors.
4. Search outcome 41 papers were found using the reported search. After removing the duplicates, there were 24 articles. Out of 24, only 17 relevant articles were found. Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 meta-analyses. Best evidence papers are shown in Table 1.
http://dx.doi.org/10.1016/j.ijsu.2015.11.041 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
N. Siddiqi et al. / International Journal of Surgery 25 (2016) 106e108
107
Table 1 Best evidence papers. Author, year & country Study type
C. Zhou et al., 2014, China [18]
Wash-out Level of Total evidence number of (n)/Local recurrence patients (%)
Statistical No rectal significance wash-out (n)/Local recurrence (%)
Comments Median follow-up after resection (Months)
Meta-analysis Level II
5519
4176/5.75% 1343/9.75%
Yes
NS
A. Matsuda et al., 2012, Meta-analysis Level II US [21]
5395
4121/5.79% 1274/10.05%
Yes
NS
F. Rondelli et al., 2012, Meta-analysis Level II UK [20] K. Kodeda et al., 2010, PNR Level III UK [6]
5024
3927/5.9%
1097/10.2%
Yes
33
4600
3749/6%
851/10.2%
Yes
60
Constantinides et al., 2008 Germany [12]
Meta-analysis Level II
432
176/4.8%
256/10.2%
No
NS
Terzi et al., 2006, Switzer-land [16]
PNR study
Level III
96
38/8%
58/3.4%
No
23
Agaba et al., 2004, Germany [11] Long et al., 1989, US [15]
RNR study
Level III
141
90/4.4%
51/5.9%
No
63
PNR study
Level III
185
40/2.6%
145/14.3%
Yes
60
Favours rectal wash out but mentions that there is no stable evidence to confirm the efficacy of rectal WO for RR or TME. Favours normal saline (500e2000 ml) over other solutions. 3 times more patients in the washout group. Favours rectal washout but different washouts and volumes utilized. 3.5 times more patients in washout group. Only 3 studies standardized TME used. 3 out of 9 studies included non-curative resections. Favours rectal washout but different washouts and volumes utilized. Favours rectal washout Looked at outcomes from the Swedish registry. 4 times more patients in the washout group Statistically not significant. Same trials included as Rondelli et al. [20], but does not include the Kodeda et al. [6] study Unequal groups. Recurrence higher in those who had washout Small sample size and follow-up duration Unequal groups Small sample size Very few in the washout group Small sample size
Abbreviations: PNR ¼ Prospective non randomized, RNR ¼ Retrospective non randomized, NS ¼ Not stated, WO ¼ Wash out, RR ¼ Radical resection, TME ¼ Total mesorectal excision.
5. Discussion Intraoperative rectal washout is performed to prevent postoperative infection and local cancer recurrence. Lloyd Davis may have been the first to perform rectal washout to prevent cancer recurrence. In 1948 he reported “Especial care must be taken to avoid implanting cancer cells”. Although there is difference in opinion on the benefit of rectal washout by different study groups, most colorectal surgeons still prefer rectal washout during anterior resection and left sided resections. Local recurrence after rectal cancer surgery may be avoided if no viable tumour cells are left behind. Colorectal tumours shed viable cells into the bowel lumen [2e4] and there is convincing evidence that these cells can deposit and increase the chances of local recurrence [2,5e8]. Rectal washout with cytotoxic agent was introduced to reduce the amount of free malignant cells. Rectal washout consists of cross clamping the rectum, distal to the tumour but proximal to the intended line of transection, followed by irrigation of the lumen from the anus to the clamp. Different types of solutions have been used, and their cytocidal effects have been studied in vitro and in vivo with conflicting results [9,10]. The overall rate of local recurrence varies from 5% to 15% according to different studies [11,12]. Church et al., stated that it is a mechanical cleansing effect of the solution rather than cytocidal effect and recommended intra-operative saline rectal washout before anastomosis [13]. Few studies have looked at the quantity of solution used for washout, but Maeda et al. suggested that more proximal tumours need a large volume of irrigation fluid [14]. Many studies have suggested different washout solutions (iodine-povidone, cetrimide, normal saline and formalin) but there is no statistical difference between whichever one is used. Long et al. [15] demonstrated a benefit in terms of local recurrence using a washout with 1% formalin solution, by contrast Terzi et al. [16] showed local recurrence rates were higher when utilising
a washout with povidone e iodine solution. They also found no difference in the presence of viable tumour cells in the staple guns with or without a washout [15,16]. Dehni et al. utilising a 5% povidone iodine solution demonstrated low recurrence rates after rectal washout [17] and Agaba et al. [11] found no benefit in terms of local recurrence using a cetrimide rectal washout. A recent meta-analysis by Zhou et al. favoured rectal wash out to reduce the incidence of local recurrence but mentioned that there was no stable evidence to confirm the efficacy of rectal wash to be practiced routinely for radical resection or total mesenteric excision and favoured saline (500e2000 ml) over other solutions [18]. Their study had 3 times more patients in the washout group and the selection criteria involved studies with no minimum trial duration including retrospective case series [18]. Another recent case control study by Xingmao et al. reviewed data of 144 patients with rectal cancer undergoing anterior resection [19]. The rectal wash out group (n ¼ 69, 1500 ml physiological saline) and the non-washout group (n ¼ 75) found no statistically significant difference (p ¼ 0.721) between the two regarding local recurrence of rectal cancer during a median follow-up of 48 month. One of the reservations regarding this study is a smaller sample size with a shorter duration of post-operative follow-up. The authors mentioned that and recommended a large-scale research with a longer follow-up [19]. A meta-analysis by Rondelli et al. strongly recommended rectal washout [20]. However the amount and type of fluid varied significantly among studies included within their analysis and so did the follow-up and hence caution is advised regarding making firm recommendations based upon their study [20]. A meta-analysis by Matsuda et al. [21], suggested that in rectal cancer there was a significant reduction in local recurrence rate using rectal washout, utilising 5 of the same studies as used by Rondelli et al. [20], but accepted that in only 3 of these studies, total
108
N. Siddiqi et al. / International Journal of Surgery 25 (2016) 106e108
mesorectal excision (TME) was utilised as the surgical technique in rectal cancer resection and in one-third (3 out of 9) of these studies, patients undergoing non-curative resections were included in the results. A study by Kodeda et al. demonstrated no statistical difference in local recurrence between the two groups but it favoured rectal washout as these patients had less local recurrence. [6] There was a good pattern of follow-up but the data was obtained from patients enrolled on the Swedish cancer registry and was more of a prospective non-randomised study and there was a bias towards rectal washout in terms of recruitment to the study [6]. Constantinides et al. recommended rectal washout after comparing 5 studies; using different solutions (cetrimide, povidone-iodine, 1% formalin and normal saline), but the differences identified were not significant [12]. No randomized study has been undertaken on this subject and almost all the studies have favoured a randomized control trial (RCT), although Kodeda et al. felt such study would need 1400 patients and a five-year follow-up which would be impractical [6]. However, with the increasing use of laparoscopic surgery, cross clamping can be technically difficult. Additionally, in all cases now, a TME rectal dissection technique is employed, which has been shown to reduce local recurrence rates [22]. Many laparoscopic surgeons do not routinely employ rectal washout so we feel it would be beneficial if we finally address this question, particularly taking into account the changes in surgical techniques employed. 6. Clinical bottom line Rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to formally address this issue, particularly taking into account the changes in surgical technique utilised in recent years would formally answer this question. 7. Conflicts of interest None. 8. Sources of funding None. 9. Ethical approval None. 10. Author contribution Dr. Dr. Dr. Dr.
Najaf Siddiqi-writing. Muhammad Abbas-writing. Zafar Iqbal-writing. Muhammad Farooq-writing.
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