- Email: [email protected]
Choice of operations for cancer of the rectosigmoid and rectum
CHOICE OF OPERATIONS #FOR CANCER THE RECTOSIGMOID AND RECTUM FRED
OF
W. RANKIN, M.D., F.A.C.S. LEXINGTON, KY.
I
N
choosing an operation for the radical extirpation of carcinoma of the rectosigmoid and rectum the first probIem which the surgeon is caIIed upon to decide usuaIIy is the answer to the patient’s query as to the necessity of a permanent coIostomy. This decision wiI1 IargeIy be influenced nationaIity, and knowIedge of by the surgeon’s experience, statistica studies of Iarge groups of cases accompIished by many types of operative maneuver. The sacra1 excision route is Iooked upon favorabIy by many Continenta surgeons, and some, American surgeons recently have advocated a one-stage resection of the rectum sacraIIy, or a simiIar resection with the preservation of the ana sphincter, or a combined abdominoperineal resection which preserves the sphincter and puIIs the sigmoid down to it. My experience with these types of operations has been too meager and unsatisfactory to draw conclusions and consequentIy in deaIing with cancer in this location I have feIt it important to utiIize as radica1 a type of excision of the growth and tissues in its immediate vicinity as is compatibIe with a sensibIe hospita1 mortaIity and an operabiIity which does not too materiaIIy reduce the scope of surgical attack. Because I am confident that Mr. Miles has accurateIy eIaborated the underIying principIes upon which to buiId a surgica1 offensive, I have foIIowed his Iead and his operation, doing it rather in two stages than in one, with resuIts which, so far as the immediate mortality is concerned, are quite satisfactory in my judgment, and what is more important, with a broadening rather than a narrowing of the horizon of operabiIity. Let me emphasize that I do not beIieve that any
760
FRED
W. RANKIN
one type of operation is appIicabIe to a11 cancers of the rectosigmoid and rectum. Here again, I wouId differentiate between cancers at the juncture of the sigmoid coIon with the rectum proper and those Iower down. I have demonstrated accurateIy in a study of IOO cases that 67 per cent of the cancers occur at the rectosigmoid, an anatomica Iocation at the juncture of the two segments of bowe12.5 cm. of which is intraperitonea1 and 2.5 cm. of which is extraperitonea1. Such operations as coIostomy and posterior resection in attack upon cancers at this Iocation are not much more than IocaI excisions, but a radica1 remova gets rid of a Iarge portion of the mesentery of the sigmoid which as Mr. MiIes has pointed out, is just as necessary of accompIishment, from the standpoint of gIanduIar invoIvement as is the dissection of the axiIIa in cancers of the breast. This is particuIarIy important when we remember that 46 per cent of a11 the recta1 and rectosigmoida1 specimens resected show gIanduIar invoIvement microscopicaIIy. That this radica1 operation then may not be empIoyed routineIy is obvious and the reason I have deviated from the origina technique of MiIes has been my inabiIity to appIy the one-stage combined abdominoperinea1 resection in a suffIcientIy high number of cases with a satisfactoriIy Iow operative mortaIity. With my own operabihty figure at 50 to 60 per cent, I have been abIe to appIy the two-stage maneuver to 46 per cent of the tota group and that with a mortaIity of 8 deaths in 85 cases, or 9.5 per cent. That a cancer of the rectum rareIy obstructs is true, but the reverse is equaIIy the case when it is Iocated in the rectosigmoid. I beIieve that the vast majority of a11 cancers of the rectosigmoid juncture at sometime during their course produce some kind of obstruction, acute, chronic, or subacute, and for this reason and for the additiona reason that they are of Iong standing before recognized, they therefore undermine and devitaIize the host. These cases never, I beIieve, except the acutely obstructed group, shouId be treated surgicaIIy without adequate preIiminary preparation and rehabiIitory treatment. The surgica1
CANCER OF RECTOSIGMOID AND RECTUM
761
offensive then is divided into three phases: (I) preoperative preparation; (2) operative technique; and (3) postoperative care. PRELIMINARY
PREPARATORY
TREATMENT
which consists essentiaIIy in Preoperative preparation, decompression and rehabiIitation, is as vita1 a consideration as is the choice of operative procedure since patients suffering from recta1 cancers are most often in advanced years and have faIIen heir to debiIitating systemic diseases, or have been reduced in their genera1 strength and weII-being by an existing neopIasm. Decompression is essentia1 because of the fact that a high percentage of a11 cases of sigmoida1 growths and true recta1 growths produce, at some time during their presence, obstruction, either subacute, chronic, or acute. The reIief of this obstruction may be accompIished generaIIy by medica measures such as repeated irrigations of the bowe1 with hot saIine, and occasionaIIy judicious administration of some miId purgative such as senna. When this faiIs, surgica1 decompression by cecostomy or colostomy is obviousIy indicated as we11 as for the group of acute obstructions. There are advantages to each of these types of drainage procedures as we11 as disadvantages, but I beIieve that in the average acutely
or subacuteIy
obstructed
case,
cecostomy
shouId
be
empIoyed rather than coIostomy. If one uses a Pezzer catheter in doing a cecostomy as Hendon suggests, one is abIe to decompress the bowe1 of gas and Iiquid materia1 very SatisfactoriIy. This reIieves the distention and increases the comfort of the patient by reducing the pain I beIieve that in the acuteIy obof ineffectua1 peristaIsis. structed cases the bIind cecostomy without expIoration is indicated. At the second stage the cecostomy is most advantageous as a decompressive maneuver if an anastomosis is attempted and if it is not attempted, stiI1 the vent is desirabIe if one is to do a combined abdominoperinea1 resection in one stage, foIIowing the decompression. I beIieve that as an aIterna-
762
FRED W. RANKIN
tive procedure where one expIores the abdomen and finds the coIon too thickened and obstructed despite medica decompressive measures to undertake a resection or manufacture
FIG. I. AbdominoperineaI resection of rectosigmoid and rectum. First stage. Abdomen is opened through a low mid-line incision and sigmoid Aexure brought out. Ligation of singIe vessel in mesentery of sigmoid cIose to bowel waII. This allows inspection under eye of bIood suppIy to both dista1 and proximal ends of bowel.
of a singIe-barreIIed coIostomy, the cecostomy is most advantageous. A second stage resection beginning from behind and going forward as in the operation I have outhned, is carried out subsequentIy and the cecostomy is a gratefu1 adjunct. During the period of decompression and vaccination, the foIIowing rehabiIitory measures are carried on: use of a high caIoric diet, the insistence on the ingestion of Iarge quantities of fluids, and routine bIood transfusions. Within the Iast year
CANCER
OF RECTOSIGMOID
AND
RECTUM
763
I have come more and more to the conviction that routine bIood transfusions in these cases, even where there is no marked anemia, have distinct advantages and I have cmpIoyed them
FIG. 2. Abdominoperineal resection of rectosigmoid and rectum. First stage. Sigmoid is divided between Payr clamps. ProximaI clamp is thrust through a stab wound in left Aank, and cIamp on distal segment is appIied in opposite direction to it. BoweI is divided with a cautery.
in practicaIIy which increases
a11 cases the safety
postoperativeIS-. Another measure factors, I beIieve, is the preoperative
administration of an intraperitoneal vaccine of mixed streptococci and coIon baciIIi. In a series of cases which has now it has been my observation that assumed Iarge proportions, this has a distinctIy beneficia1 result. While I do not urge that aIone it wouId have an influence on mortaIity, I do beIieve that theoreticaIIy it is correct, and practicaIIy, it has a distinct pIace as one step in increasing the individual’s resistance to infection. It is usuaIIy given three days prior to operation and
764
FRED
W. RANKIN
has a systemic reaction aImost invariabIy. To bring a patient to operation with a cIean unobstructed bowe1 and a physioIogic equiIibrium raised to as near norma as is possibIe in the short
FIG. 3. Abdominoperineal resection of rectosigmoid and rectum. First end of divided bowe1 is drawn out through stab wound, and dista1 and dropped back. Insert shows abdominal wound cIosed, and clamp portion of sigmoid. CIamp is to be removed at end of forty-eight to
stage. Proximal end is turned in hoIding proxima1 sixty hours.
period of time avaiIabIe, increases the safety factors of surgery and undoubtedIy enhances the end-resuks foIIowing successful extirpation.
CANCER
OF RECTOSIGMOID
AND
RECTUll
765
ANESTHETIC
The choice of anesthetic for combined abdominoperinea1 resections of the rectum is a not unimportant probIem. That
FIG. 4. AbdominoperineaI
resection of rectosigmoid and rectum. Second stage. Posterior approach. Anus is cIosed with a purse-string suture and two IateraI incisions encircle it, extending upward to sacrococcygea1 articulation. Mobilization of rectum is shown. Coccyx has been removed.
it is still an unsoIved one is evidenced by the multiple types of anesthetics advocated by numerous operating surgeons. My own advocacy of spina anesthesia as the method of choice continued unabated over a period of years until I suffered an operating room casuaIty which was rapidIy foIIowed by another one, and in consequence my faith in its routine use was shaken. That it has a definite pIace in this fieId of surgery is unquestionabIy true, and yet its Iimitations and indications are, I feel, far from being distinctIy outlined. In recent years my own choice of anesthetic has been a reIativeIy satisfactory one. The first stage of the operation, at which expIoration of the peritonea1 cavity and then manufacture of a coIostomy are ac-
766
FRED
W. RANKIN
comphshed, is carried out under gas-oxygen-ether, or ethyIene. The second stage of the operation which is begun from behind and carried forward, is done first under transsacra1 anesthesia
FIG. 5. Abdominoperineal
resection
of rectosigmoid
and rectum.
Second stage. Rectum
has been compIeteIy mobilized up to peritoneum which has not been opened. It is encased in a rubber gIove and thrust back into hollow of sacrum. Insert shows wound cIosed.
and when the patient is turned over and the abdomen is opened for a second time, then again ethyIene or gas-oxygen-ether is used. This routine in my hands has proved comfortabIe and satisfactory and I beIieve is foIIowed by as few postoperative compIications as any type at present in vogue. The constant advances in anesthesia, the deveIopment of adequate preIiminary medication, and the proper postoperative treatment to avoid puImonary complications a11 have improved the safety factors for the patient, yet without, I feeI, having up to now attained an idea1 type of anesthesia.
CANCER
OF RECTOSIGMOID
AND
RECTUM
767
TECHNIQUE
Stage. abdominoperinea1 First
The first operation,
stage of the graded combined consists of an abdomina1 search
FIG. 6. Abdominoperineal resection of rectosigmoid and rectum. Second stage. Anterior approach. Peritoneum has been divided on either side of mesentery. Blood suppIy in mesentery and left ureter are exposed. Peritoneal attachment to bIadder has been divided.
for metastases, and the estabhshment of a singIe-barreIIed coIostomy. That the expIoration shouId be carried out in a routine manner, beginning with the upper abdomen, and expIoring the growth Iast, is obvious. The expIoration is best made through a low mid-Iine incision, which need not be Iarge, but onIy suffrcientIy roomy to admit the searching hand; and secondIy, the manufacture of
768
FRED
W. RANKIN
the coIostomy, without interference. These wounds may be seaIed off from the coIostomy, and usuaIIy heaI niceIy. On opening the peritoneum, the gIoved hand is thrust
FIG. 7. Abdominoperineal resection of rectosigmoid and rectum. Second stage. Ligation of inferior mesenteric vessels close to their origins.
upward to the Iiver, the surfaces of which are carefuIIy paIpated for metastatic noduIes. Then the expIoration proceeds from above, downward. The presence or absence of gIands around the pancreas and aIong the aorta is noted, as we11 as in the bifurcation of the common iIiac arteries. LastIy, the peIvis is expIored for deposits on the peIvic peritoneum, and the growth is feIt IightIy and gingerIy to test its mobiIity, and to estimate the chances of resecting it. One cannot approach to the IocaI growth, because of the infective organisms in the pericoIonic tissue. It is a weII-estabIished fact that the permeabihty of the Iarge bowe1 to organisms is hugeIy increased by two factors,
CANCER OF RECTOSIGMOID AND RECTUM
7%
nameIy, ukeration and obstruction. Both of these factors are almost always present in rectosigmoida1 growths and vigorous manipuIation at expIoration may spread organisms in the
FIG. 8. Abdominoperineal resection of rectosigmoid and rectum. Second stage. Entire rectum being Iefted out from pelvis. Insert shows a new diaphragm has been made by suturing peIvic peritoneum.
peritoneal cavity with a resuIting widespread infection. It is my considered opinion that peritonitis, which is the IethaI factor in the majority of unsuccessfu1 resections of the coIon and rectum, more often foIIows spread of infective organisms by manipuIation at exploration, or in the course of mobiIization of the growth than from failure of the suture Iine to hoId. If metastases are not demonstrated at expIoration, and it is decided that the growth is rescctabIe, a convenient portion of the sigmoid that is the highest point in the Ioop is seIected for the coIostomy. The mescntcq- cIose to the bowe1
770
FRED
W. RANKIN
is divided, but onIy suffIcientIy wideIy to permit the proxima1 end of the bowe1 to be drawn out through a stab wound in the groin; whiIe the dista1 end is inverted and returned to the peritonea1 cavity. The utmost care is taken to estabIish under actua1 vision that the bIood suppIy to both ends of the bowe1 is not interfered with. Steward and I have shown that the bIood suppIy to the Iarge bowe1 is very constantIy and definiteIy distributed, aIthough not so richIy as that of the smaIIer intestine; so, unIess the mesentery contains a great quantity of fat, it is easy to demonstrate the Iooping arches of the inferior mesenteric artery and to prevent unnecessary sacrifice of essentia1 vesseIs. The bowe1 is divided between two Payr cIamps, the upper one of which has been thrust through a stab wound in the flank, seIected as the site most satisfactory for taking care of a coIostomy apparatus. The second cIamp is approximated to this, but appIied in the opposite direction, the bowe1 is then cut across with a cautery and the proxima1 end is drawn out, whiIe the dista1 end is inverted and dropped back. The cIamp on the proxima1 end compIeteIy obstructs the bowe1, and is aIIowed to remain in situ for forty-eight to seventy-two hours. Men invariably toIerate this obstruction and gas accumuIation Iess readiIy than women. Sutures are not pIaced in the bowe1 waI1 to attach the coIostomy to the peritoneum. The stab wound is made through the muscuIature of the abdomina1 waI1 and is onIy suffIcientIy Iarge’to aIIow the bowe1 to be puIIed out easiIy. Two important points in estabIishing a coIostomy, from the patient’s standpoint, are the prevention of proIapse of the mucous membrane of the bowe1, and herniation around the coIostomy. If one may accompIish a singIe-barreIIed coIostomy without hernia or proIapse and the individua1 estabIishcorrect bowe1 habits, so Iong as the stooIs are formed and the Iower bowe1 emptied once or, at most, twice a day, IittIe discomfort resuIts therefrom. The question of not suturing the peritoneum of the bowe1 to the peritoneum of the abdomina1 waI1, has, in my experience,
CANCER
OF RECTOSIGMOID
AND
RECTUM
7’1
justified itseIf. Without sutures, nature estabIishes a snug aggIutination in the first forty-eight hours, and I have observed no tendency on the part of the Ioop to retract. It is questionabIe whether the mortaIity is higher in manufacturing coIostomies of this type than in the ordinary Ioop coIostomy in which the bowe1 is not divided. My own mortality, incIuding a11 types of coIostomies, has been 3.5 per cent in operabIe cases, and twice that high in cases found inoperabIe for various reasons, but nevertheIess expIored. Second Stage. The time for carrying out the second stage of the combined maneuver varies, but usuaIIy a month to six weeks between stages wiI1 be considered the optimum period of waiting. The unpIeasant objection that the cancer in the meantime may metastasize cannot be avoided, but I think the fact that these peopIe have known of bowe1 symptoms sometimes for a period of ten or more months before seeking advice counterbalances this deIay, if by so doing one may extend the scope of the operation. Between stages efforts are strenuousIy directed toward rehabiIitation as we11 as reduction of the infection around the local growth. Recta1 irrigations are instituted about the tenth postoperative day and are continued daiIy up to the time of the second stage. A two-way recta1 tube has proved a most satisfactory method of cleansing the bowe1 without exerting undue pressure on the inverted stump. Every effort at rehabihtation is urged. It has been my experience that these patients improve rather quickIy after the obstruction of the bow4 is reIieved, and efforts are made to buiId up their general strength. The resection is done by beginning posteriorIy but finaIIy ending up with an abdomina1 incision aIso. This posterior method of partial mobiIization permits extensive dissection of the peIvis up to the peritoneum. It is possibIe thus, without opening the peritoneal cavity, to cIean out the hoIIow of the sacrum and ischiorectal fossa, sacrificing the Ievator ani muscIe and cIearing away the gIand-bearing tissues around the prostate gIand and semina1 vesicIes in the maIe and from
772
FRED W. RANKIN
the posterior vagina1 waII, cervix, and broad ligaments in the femaIe. The patient is pIaced face downward on the tabIe as for a posterior type of resection with the hips eIevated and the anus cIosed with a pursestring suture. The anus is encircIed with two incisions which are carried up and joined a IittIe above the sacrococcygea1 articuIation. Undermining these incisions, it is possibIe to remove as much fat and gIand-bearing tissue from the ischiorecta1 fossa as is necessary, and at the same time, sacrifice a great portion of the Ievator ani muscle. The coccyx is disarticuIated from the sacrum, and dividing the fascia propria opposite the sacrococcygea1 articuIation, a bIunt dissection of the hoIIow of the sacrum foIIows. The Iateral dissection is now carried compIeteIy up to the peritoneum, which is not opened. The rectum is now encased in a rubber gIove, which is tied tightIy around the cuff, and pushed back into the hoIIow of the sacrum and the posterior wound cIosed. Up to now the peritoneum has not been opened and the operation has been carried on under transsacra1 anesthesia. The patient is now turned on his back and the anterior part of the dissection carried out. The Iow mid-Iine incision which was used for expIoration is opened again and enIarged to extend from the symphysis to an inch above and to the Ieft of the umbiIicus. No expIoring is done. The peIvis is carefuIIy packed off with wet sponges and the turned-in end of the bowe1 sought. The peritoneum over the inferior mesenteric vesseIs is incised and both ureters identified. The Ieft ureter runs cIose to the vesseIs, but the right one is we11 away from them. The inferior mesenteric vesseIs are now Iigated cIose to their origin and doubIy Iigated if there is much fat in the mesentery. Excepting onIy the middIe sacra1 artery, the termina1 branch of the aorta, practicaIIy a11of the blood supply is thus tied. The incisions in the peritoneum are carried forward toward the base of the bIadder on both sides, and the bIadder is separated from the rectum. With gauze dissection the gIandbearing tissues on both sides of the bowe1 are wiped mesiaIIy
CANCER
OF RECTOSIGMOID
AND RECTUILI
773
and the entire segment is Iifted out through the abdomen. PeritoneaIization of the peIvis is quickIy and easiIy made. There is no diffIcuIty in peritoneaIizing the femaIe peIvis because the broad Iigaments and the uterus may be substituted for any defect Ieft. In the maIe, with a IittIe care in making the peritonea1 flaps, one may aIso manufacture a new peIvic diaphragm with IittIe effort. The abdomina1 wound is cIosed and drainage of the peIvis is made by opening the posterior wound and inserting a tube, and if necessary to contro1 oozing, a smaI1 gauze pack. The Iarge cavity made by the dissection must obviousIy hea bJ granuIation. The second stage of the operation is not usuaIIy difEcuIt, and whiIe it has the disadvantage of opening the abdomen twice in a short period, I fee1 that it not onIy utiIizes the most satisfactory principIes of a radica1 procedure, but at the same time extends the scope of the operation without increasing, and with a possibIe Iowering, of the immediate mortahty. POSTOPERATIVE
TREATMENT
PostoperativeIy I have made it a rule to insist upon abstinence from fluids of any kind for forty-eight to sixty hours. During this time adequate amounts of narcotics are suppIied not onIy to keep the patient comfortabIe, but aIso to quiet any peristaItic movements. I beIieve that a good test of the time to begin administration of food and fluid by mouth is the passage of gas from the coIostomy. Adequate hydration is accompIished by the administration of at Ieast 3000 to 4009 C.C. of fluids by hypodermocIysis or venoclysis during each twenty-four hours. We have recentIy routineIy instituted postoperative blood transfusions in a11 cases of bowel or recta1 restrictions. It apparentIy has a most beneficia1 effect upon these cases, not onIy in reducing immediate postoperative reaction, but in promoting a smoother and Iess compIicated ConvaIescence. Complications are treated in a routine manner as they arise, with the exception of one, nameIy, parotitis,
774
FRED W. RANKIN
which seems to be much more IikeIy to deveIop after an operation upon the Iarge bowe1 and rectum than it does in the course of operation for other chronic Iesions. In a series of cases which I studied in 1930, there was one case in each 135 operations on the coIon and rectum which deveIoped parotitis. This is nearIy 17 times as many as the number encountered in genera1 surgica1 cases. The use of radium appIied as earIy as possibIe after the beginning of sweIIing appeared to be the treatment of choice, and not onIy did it avoid incision of the parotid gland in the majority of instances, but at the same time influenced most favorabIy the prognosis. The most important point in using radium is to appIy it earIy and in doses which consist of four appIications, eight hours in duration, at intervaIs of eight hours, of four 50 mg. tubes. The care of the postoperative wound foIIowing the second stage of the procedure is of importance and is best carried out by attendants who are accustomed to handIing such cases. For the first seventy-two hours the wound is untouched except for changing the outside dressings. There wiI1 be a smaI1 amount of serosanguinous drainage, but not a great dea1. At the end of seventy-two hours it is desirabIe to remove the gauze pack and begin hot irrigations. The gauze pack is removed after carefuIIy soaking it with peroxide of hydrogen, and pain may be done away with by the administration of some of the barbiturates. Two irrigations a day are generaIIy empIoyed after remova of the pack, of either a physioIogica1 soIution of sodium chIoride or a soIution of potassium permanganate I :5000. Irrigations are aIso suppIemented by heat from an arc of carbon filament Iamp which is empIoyed twice daiIy. It is astounding how few of these wounds deveIop severe infections, and how readiIy most of them hea up. UsuaIIy it is a matter of two or three months before they are entireIy heaIed, but I have seen one instance in which the posterior wound had heaIed, except a smaI1 superficia1 granuIating surface, by the end of the twenty-seventh day.
CANCER OF RECTOSIGMOID AND RECTUM
-yi
The care of the coIostomy is an important consideration and is handicapped rather than advantaged by the use of any compIicated or combersome bag or attachment to receive the feca1 materia1 from the stoma. Since abandoning a11 such apparatus and reIying upon a simpIe eIastic beIt which is much Iike an ordinary abdomina1 supporter, and in which is pIaced a removabIe rubber mat about 8 inches square, I have found that these patients are much more comfortabIe. They cIeanse and irrigate the bowe1 once a day, pIace a smaI1 amount of cotton or tissue paper over the stoma, and over this appIy the simpIe beIt. So Iong as the stooIs are formed there is scant IikeIihood of unpIeasant accidents except for the escape of gases. When the boweIs are Ioose, any coIostomy is intoIerabIe and no type of apparatus is satisfactory. The menta1 attitude of the patient toward the care of his coIostomy, and attention to his diet, are important factors in his comfort. The uItimate end-resuIts foIIowing successfu1 extirpation of maIignancies of the rectum by radica1 means have been proved by statistica studies of a Iong series of cases by man? surgeons. Whether the operative type of procedure can be accompIished in one stage or two, I think, depends upon a great many factors, but the probIem of greatest importance is to adjust operative technique to the whoIe group of cases in such a manner that each individual will receive the best chance of Iongevity by utilizing the maneuver most suitabIe for the individua1 case. That no routine measure is adaptabIe to aII, seems obvious. I beIieve that procedures which are compatibIe with a mortahty rate of around IO per cent shouId be instituted in every case as judgment indicates. That there shouId not be a marked Iowering in the operabiIity curve seems most essentia1. The very fact that 46 per cent of the removed specimens show gIanduIar invoIvement seems adequate reason for appIying a maneuver to cancers of the rectum and rectosigmoid which wiI1 extend the operative &Id beyond the IocaI growth and the first group of glands in immediate juxtaposition to it.
OF
W. RANKIN, M.D., F.A.C.S. LEXINGTON, KY.
I
N
choosing an operation for the radical extirpation of carcinoma of the rectosigmoid and rectum the first probIem which the surgeon is caIIed upon to decide usuaIIy is the answer to the patient’s query as to the necessity of a permanent coIostomy. This decision wiI1 IargeIy be influenced nationaIity, and knowIedge of by the surgeon’s experience, statistica studies of Iarge groups of cases accompIished by many types of operative maneuver. The sacra1 excision route is Iooked upon favorabIy by many Continenta surgeons, and some, American surgeons recently have advocated a one-stage resection of the rectum sacraIIy, or a simiIar resection with the preservation of the ana sphincter, or a combined abdominoperineal resection which preserves the sphincter and puIIs the sigmoid down to it. My experience with these types of operations has been too meager and unsatisfactory to draw conclusions and consequentIy in deaIing with cancer in this location I have feIt it important to utiIize as radica1 a type of excision of the growth and tissues in its immediate vicinity as is compatibIe with a sensibIe hospita1 mortaIity and an operabiIity which does not too materiaIIy reduce the scope of surgical attack. Because I am confident that Mr. Miles has accurateIy eIaborated the underIying principIes upon which to buiId a surgica1 offensive, I have foIIowed his Iead and his operation, doing it rather in two stages than in one, with resuIts which, so far as the immediate mortality is concerned, are quite satisfactory in my judgment, and what is more important, with a broadening rather than a narrowing of the horizon of operabiIity. Let me emphasize that I do not beIieve that any
760
FRED
W. RANKIN
one type of operation is appIicabIe to a11 cancers of the rectosigmoid and rectum. Here again, I wouId differentiate between cancers at the juncture of the sigmoid coIon with the rectum proper and those Iower down. I have demonstrated accurateIy in a study of IOO cases that 67 per cent of the cancers occur at the rectosigmoid, an anatomica Iocation at the juncture of the two segments of bowe12.5 cm. of which is intraperitonea1 and 2.5 cm. of which is extraperitonea1. Such operations as coIostomy and posterior resection in attack upon cancers at this Iocation are not much more than IocaI excisions, but a radica1 remova gets rid of a Iarge portion of the mesentery of the sigmoid which as Mr. MiIes has pointed out, is just as necessary of accompIishment, from the standpoint of gIanduIar invoIvement as is the dissection of the axiIIa in cancers of the breast. This is particuIarIy important when we remember that 46 per cent of a11 the recta1 and rectosigmoida1 specimens resected show gIanduIar invoIvement microscopicaIIy. That this radica1 operation then may not be empIoyed routineIy is obvious and the reason I have deviated from the origina technique of MiIes has been my inabiIity to appIy the one-stage combined abdominoperinea1 resection in a suffIcientIy high number of cases with a satisfactoriIy Iow operative mortaIity. With my own operabihty figure at 50 to 60 per cent, I have been abIe to appIy the two-stage maneuver to 46 per cent of the tota group and that with a mortaIity of 8 deaths in 85 cases, or 9.5 per cent. That a cancer of the rectum rareIy obstructs is true, but the reverse is equaIIy the case when it is Iocated in the rectosigmoid. I beIieve that the vast majority of a11 cancers of the rectosigmoid juncture at sometime during their course produce some kind of obstruction, acute, chronic, or subacute, and for this reason and for the additiona reason that they are of Iong standing before recognized, they therefore undermine and devitaIize the host. These cases never, I beIieve, except the acutely obstructed group, shouId be treated surgicaIIy without adequate preIiminary preparation and rehabiIitory treatment. The surgica1
CANCER OF RECTOSIGMOID AND RECTUM
761
offensive then is divided into three phases: (I) preoperative preparation; (2) operative technique; and (3) postoperative care. PRELIMINARY
PREPARATORY
TREATMENT
which consists essentiaIIy in Preoperative preparation, decompression and rehabiIitation, is as vita1 a consideration as is the choice of operative procedure since patients suffering from recta1 cancers are most often in advanced years and have faIIen heir to debiIitating systemic diseases, or have been reduced in their genera1 strength and weII-being by an existing neopIasm. Decompression is essentia1 because of the fact that a high percentage of a11 cases of sigmoida1 growths and true recta1 growths produce, at some time during their presence, obstruction, either subacute, chronic, or acute. The reIief of this obstruction may be accompIished generaIIy by medica measures such as repeated irrigations of the bowe1 with hot saIine, and occasionaIIy judicious administration of some miId purgative such as senna. When this faiIs, surgica1 decompression by cecostomy or colostomy is obviousIy indicated as we11 as for the group of acute obstructions. There are advantages to each of these types of drainage procedures as we11 as disadvantages, but I beIieve that in the average acutely
or subacuteIy
obstructed
case,
cecostomy
shouId
be
empIoyed rather than coIostomy. If one uses a Pezzer catheter in doing a cecostomy as Hendon suggests, one is abIe to decompress the bowe1 of gas and Iiquid materia1 very SatisfactoriIy. This reIieves the distention and increases the comfort of the patient by reducing the pain I beIieve that in the acuteIy obof ineffectua1 peristaIsis. structed cases the bIind cecostomy without expIoration is indicated. At the second stage the cecostomy is most advantageous as a decompressive maneuver if an anastomosis is attempted and if it is not attempted, stiI1 the vent is desirabIe if one is to do a combined abdominoperinea1 resection in one stage, foIIowing the decompression. I beIieve that as an aIterna-
762
FRED W. RANKIN
tive procedure where one expIores the abdomen and finds the coIon too thickened and obstructed despite medica decompressive measures to undertake a resection or manufacture
FIG. I. AbdominoperineaI resection of rectosigmoid and rectum. First stage. Abdomen is opened through a low mid-line incision and sigmoid Aexure brought out. Ligation of singIe vessel in mesentery of sigmoid cIose to bowel waII. This allows inspection under eye of bIood suppIy to both dista1 and proximal ends of bowel.
of a singIe-barreIIed coIostomy, the cecostomy is most advantageous. A second stage resection beginning from behind and going forward as in the operation I have outhned, is carried out subsequentIy and the cecostomy is a gratefu1 adjunct. During the period of decompression and vaccination, the foIIowing rehabiIitory measures are carried on: use of a high caIoric diet, the insistence on the ingestion of Iarge quantities of fluids, and routine bIood transfusions. Within the Iast year
CANCER
OF RECTOSIGMOID
AND
RECTUM
763
I have come more and more to the conviction that routine bIood transfusions in these cases, even where there is no marked anemia, have distinct advantages and I have cmpIoyed them
FIG. 2. Abdominoperineal resection of rectosigmoid and rectum. First stage. Sigmoid is divided between Payr clamps. ProximaI clamp is thrust through a stab wound in left Aank, and cIamp on distal segment is appIied in opposite direction to it. BoweI is divided with a cautery.
in practicaIIy which increases
a11 cases the safety
postoperativeIS-. Another measure factors, I beIieve, is the preoperative
administration of an intraperitoneal vaccine of mixed streptococci and coIon baciIIi. In a series of cases which has now it has been my observation that assumed Iarge proportions, this has a distinctIy beneficia1 result. While I do not urge that aIone it wouId have an influence on mortaIity, I do beIieve that theoreticaIIy it is correct, and practicaIIy, it has a distinct pIace as one step in increasing the individual’s resistance to infection. It is usuaIIy given three days prior to operation and
764
FRED
W. RANKIN
has a systemic reaction aImost invariabIy. To bring a patient to operation with a cIean unobstructed bowe1 and a physioIogic equiIibrium raised to as near norma as is possibIe in the short
FIG. 3. Abdominoperineal resection of rectosigmoid and rectum. First end of divided bowe1 is drawn out through stab wound, and dista1 and dropped back. Insert shows abdominal wound cIosed, and clamp portion of sigmoid. CIamp is to be removed at end of forty-eight to
stage. Proximal end is turned in hoIding proxima1 sixty hours.
period of time avaiIabIe, increases the safety factors of surgery and undoubtedIy enhances the end-resuks foIIowing successful extirpation.
CANCER
OF RECTOSIGMOID
AND
RECTUll
765
ANESTHETIC
The choice of anesthetic for combined abdominoperinea1 resections of the rectum is a not unimportant probIem. That
FIG. 4. AbdominoperineaI
resection of rectosigmoid and rectum. Second stage. Posterior approach. Anus is cIosed with a purse-string suture and two IateraI incisions encircle it, extending upward to sacrococcygea1 articulation. Mobilization of rectum is shown. Coccyx has been removed.
it is still an unsoIved one is evidenced by the multiple types of anesthetics advocated by numerous operating surgeons. My own advocacy of spina anesthesia as the method of choice continued unabated over a period of years until I suffered an operating room casuaIty which was rapidIy foIIowed by another one, and in consequence my faith in its routine use was shaken. That it has a definite pIace in this fieId of surgery is unquestionabIy true, and yet its Iimitations and indications are, I feel, far from being distinctIy outlined. In recent years my own choice of anesthetic has been a reIativeIy satisfactory one. The first stage of the operation, at which expIoration of the peritonea1 cavity and then manufacture of a coIostomy are ac-
766
FRED
W. RANKIN
comphshed, is carried out under gas-oxygen-ether, or ethyIene. The second stage of the operation which is begun from behind and carried forward, is done first under transsacra1 anesthesia
FIG. 5. Abdominoperineal
resection
of rectosigmoid
and rectum.
Second stage. Rectum
has been compIeteIy mobilized up to peritoneum which has not been opened. It is encased in a rubber gIove and thrust back into hollow of sacrum. Insert shows wound cIosed.
and when the patient is turned over and the abdomen is opened for a second time, then again ethyIene or gas-oxygen-ether is used. This routine in my hands has proved comfortabIe and satisfactory and I beIieve is foIIowed by as few postoperative compIications as any type at present in vogue. The constant advances in anesthesia, the deveIopment of adequate preIiminary medication, and the proper postoperative treatment to avoid puImonary complications a11 have improved the safety factors for the patient, yet without, I feeI, having up to now attained an idea1 type of anesthesia.
CANCER
OF RECTOSIGMOID
AND
RECTUM
767
TECHNIQUE
Stage. abdominoperinea1 First
The first operation,
stage of the graded combined consists of an abdomina1 search
FIG. 6. Abdominoperineal resection of rectosigmoid and rectum. Second stage. Anterior approach. Peritoneum has been divided on either side of mesentery. Blood suppIy in mesentery and left ureter are exposed. Peritoneal attachment to bIadder has been divided.
for metastases, and the estabhshment of a singIe-barreIIed coIostomy. That the expIoration shouId be carried out in a routine manner, beginning with the upper abdomen, and expIoring the growth Iast, is obvious. The expIoration is best made through a low mid-Iine incision, which need not be Iarge, but onIy suffrcientIy roomy to admit the searching hand; and secondIy, the manufacture of
768
FRED
W. RANKIN
the coIostomy, without interference. These wounds may be seaIed off from the coIostomy, and usuaIIy heaI niceIy. On opening the peritoneum, the gIoved hand is thrust
FIG. 7. Abdominoperineal resection of rectosigmoid and rectum. Second stage. Ligation of inferior mesenteric vessels close to their origins.
upward to the Iiver, the surfaces of which are carefuIIy paIpated for metastatic noduIes. Then the expIoration proceeds from above, downward. The presence or absence of gIands around the pancreas and aIong the aorta is noted, as we11 as in the bifurcation of the common iIiac arteries. LastIy, the peIvis is expIored for deposits on the peIvic peritoneum, and the growth is feIt IightIy and gingerIy to test its mobiIity, and to estimate the chances of resecting it. One cannot approach to the IocaI growth, because of the infective organisms in the pericoIonic tissue. It is a weII-estabIished fact that the permeabihty of the Iarge bowe1 to organisms is hugeIy increased by two factors,
CANCER OF RECTOSIGMOID AND RECTUM
7%
nameIy, ukeration and obstruction. Both of these factors are almost always present in rectosigmoida1 growths and vigorous manipuIation at expIoration may spread organisms in the
FIG. 8. Abdominoperineal resection of rectosigmoid and rectum. Second stage. Entire rectum being Iefted out from pelvis. Insert shows a new diaphragm has been made by suturing peIvic peritoneum.
peritoneal cavity with a resuIting widespread infection. It is my considered opinion that peritonitis, which is the IethaI factor in the majority of unsuccessfu1 resections of the coIon and rectum, more often foIIows spread of infective organisms by manipuIation at exploration, or in the course of mobiIization of the growth than from failure of the suture Iine to hoId. If metastases are not demonstrated at expIoration, and it is decided that the growth is rescctabIe, a convenient portion of the sigmoid that is the highest point in the Ioop is seIected for the coIostomy. The mescntcq- cIose to the bowe1
770
FRED
W. RANKIN
is divided, but onIy suffIcientIy wideIy to permit the proxima1 end of the bowe1 to be drawn out through a stab wound in the groin; whiIe the dista1 end is inverted and returned to the peritonea1 cavity. The utmost care is taken to estabIish under actua1 vision that the bIood suppIy to both ends of the bowe1 is not interfered with. Steward and I have shown that the bIood suppIy to the Iarge bowe1 is very constantIy and definiteIy distributed, aIthough not so richIy as that of the smaIIer intestine; so, unIess the mesentery contains a great quantity of fat, it is easy to demonstrate the Iooping arches of the inferior mesenteric artery and to prevent unnecessary sacrifice of essentia1 vesseIs. The bowe1 is divided between two Payr cIamps, the upper one of which has been thrust through a stab wound in the flank, seIected as the site most satisfactory for taking care of a coIostomy apparatus. The second cIamp is approximated to this, but appIied in the opposite direction, the bowe1 is then cut across with a cautery and the proxima1 end is drawn out, whiIe the dista1 end is inverted and dropped back. The cIamp on the proxima1 end compIeteIy obstructs the bowe1, and is aIIowed to remain in situ for forty-eight to seventy-two hours. Men invariably toIerate this obstruction and gas accumuIation Iess readiIy than women. Sutures are not pIaced in the bowe1 waI1 to attach the coIostomy to the peritoneum. The stab wound is made through the muscuIature of the abdomina1 waI1 and is onIy suffIcientIy Iarge’to aIIow the bowe1 to be puIIed out easiIy. Two important points in estabIishing a coIostomy, from the patient’s standpoint, are the prevention of proIapse of the mucous membrane of the bowe1, and herniation around the coIostomy. If one may accompIish a singIe-barreIIed coIostomy without hernia or proIapse and the individua1 estabIishcorrect bowe1 habits, so Iong as the stooIs are formed and the Iower bowe1 emptied once or, at most, twice a day, IittIe discomfort resuIts therefrom. The question of not suturing the peritoneum of the bowe1 to the peritoneum of the abdomina1 waI1, has, in my experience,
CANCER
OF RECTOSIGMOID
AND
RECTUM
7’1
justified itseIf. Without sutures, nature estabIishes a snug aggIutination in the first forty-eight hours, and I have observed no tendency on the part of the Ioop to retract. It is questionabIe whether the mortaIity is higher in manufacturing coIostomies of this type than in the ordinary Ioop coIostomy in which the bowe1 is not divided. My own mortality, incIuding a11 types of coIostomies, has been 3.5 per cent in operabIe cases, and twice that high in cases found inoperabIe for various reasons, but nevertheIess expIored. Second Stage. The time for carrying out the second stage of the combined maneuver varies, but usuaIIy a month to six weeks between stages wiI1 be considered the optimum period of waiting. The unpIeasant objection that the cancer in the meantime may metastasize cannot be avoided, but I think the fact that these peopIe have known of bowe1 symptoms sometimes for a period of ten or more months before seeking advice counterbalances this deIay, if by so doing one may extend the scope of the operation. Between stages efforts are strenuousIy directed toward rehabiIitation as we11 as reduction of the infection around the local growth. Recta1 irrigations are instituted about the tenth postoperative day and are continued daiIy up to the time of the second stage. A two-way recta1 tube has proved a most satisfactory method of cleansing the bowe1 without exerting undue pressure on the inverted stump. Every effort at rehabihtation is urged. It has been my experience that these patients improve rather quickIy after the obstruction of the bow4 is reIieved, and efforts are made to buiId up their general strength. The resection is done by beginning posteriorIy but finaIIy ending up with an abdomina1 incision aIso. This posterior method of partial mobiIization permits extensive dissection of the peIvis up to the peritoneum. It is possibIe thus, without opening the peritoneal cavity, to cIean out the hoIIow of the sacrum and ischiorectal fossa, sacrificing the Ievator ani muscIe and cIearing away the gIand-bearing tissues around the prostate gIand and semina1 vesicIes in the maIe and from
772
FRED W. RANKIN
the posterior vagina1 waII, cervix, and broad ligaments in the femaIe. The patient is pIaced face downward on the tabIe as for a posterior type of resection with the hips eIevated and the anus cIosed with a pursestring suture. The anus is encircIed with two incisions which are carried up and joined a IittIe above the sacrococcygea1 articuIation. Undermining these incisions, it is possibIe to remove as much fat and gIand-bearing tissue from the ischiorecta1 fossa as is necessary, and at the same time, sacrifice a great portion of the Ievator ani muscle. The coccyx is disarticuIated from the sacrum, and dividing the fascia propria opposite the sacrococcygea1 articuIation, a bIunt dissection of the hoIIow of the sacrum foIIows. The Iateral dissection is now carried compIeteIy up to the peritoneum, which is not opened. The rectum is now encased in a rubber gIove, which is tied tightIy around the cuff, and pushed back into the hoIIow of the sacrum and the posterior wound cIosed. Up to now the peritoneum has not been opened and the operation has been carried on under transsacra1 anesthesia. The patient is now turned on his back and the anterior part of the dissection carried out. The Iow mid-Iine incision which was used for expIoration is opened again and enIarged to extend from the symphysis to an inch above and to the Ieft of the umbiIicus. No expIoring is done. The peIvis is carefuIIy packed off with wet sponges and the turned-in end of the bowe1 sought. The peritoneum over the inferior mesenteric vesseIs is incised and both ureters identified. The Ieft ureter runs cIose to the vesseIs, but the right one is we11 away from them. The inferior mesenteric vesseIs are now Iigated cIose to their origin and doubIy Iigated if there is much fat in the mesentery. Excepting onIy the middIe sacra1 artery, the termina1 branch of the aorta, practicaIIy a11of the blood supply is thus tied. The incisions in the peritoneum are carried forward toward the base of the bIadder on both sides, and the bIadder is separated from the rectum. With gauze dissection the gIandbearing tissues on both sides of the bowe1 are wiped mesiaIIy
CANCER
OF RECTOSIGMOID
AND RECTUILI
773
and the entire segment is Iifted out through the abdomen. PeritoneaIization of the peIvis is quickIy and easiIy made. There is no diffIcuIty in peritoneaIizing the femaIe peIvis because the broad Iigaments and the uterus may be substituted for any defect Ieft. In the maIe, with a IittIe care in making the peritonea1 flaps, one may aIso manufacture a new peIvic diaphragm with IittIe effort. The abdomina1 wound is cIosed and drainage of the peIvis is made by opening the posterior wound and inserting a tube, and if necessary to contro1 oozing, a smaI1 gauze pack. The Iarge cavity made by the dissection must obviousIy hea bJ granuIation. The second stage of the operation is not usuaIIy difEcuIt, and whiIe it has the disadvantage of opening the abdomen twice in a short period, I fee1 that it not onIy utiIizes the most satisfactory principIes of a radica1 procedure, but at the same time extends the scope of the operation without increasing, and with a possibIe Iowering, of the immediate mortahty. POSTOPERATIVE
TREATMENT
PostoperativeIy I have made it a rule to insist upon abstinence from fluids of any kind for forty-eight to sixty hours. During this time adequate amounts of narcotics are suppIied not onIy to keep the patient comfortabIe, but aIso to quiet any peristaItic movements. I beIieve that a good test of the time to begin administration of food and fluid by mouth is the passage of gas from the coIostomy. Adequate hydration is accompIished by the administration of at Ieast 3000 to 4009 C.C. of fluids by hypodermocIysis or venoclysis during each twenty-four hours. We have recentIy routineIy instituted postoperative blood transfusions in a11 cases of bowel or recta1 restrictions. It apparentIy has a most beneficia1 effect upon these cases, not onIy in reducing immediate postoperative reaction, but in promoting a smoother and Iess compIicated ConvaIescence. Complications are treated in a routine manner as they arise, with the exception of one, nameIy, parotitis,
774
FRED W. RANKIN
which seems to be much more IikeIy to deveIop after an operation upon the Iarge bowe1 and rectum than it does in the course of operation for other chronic Iesions. In a series of cases which I studied in 1930, there was one case in each 135 operations on the coIon and rectum which deveIoped parotitis. This is nearIy 17 times as many as the number encountered in genera1 surgica1 cases. The use of radium appIied as earIy as possibIe after the beginning of sweIIing appeared to be the treatment of choice, and not onIy did it avoid incision of the parotid gland in the majority of instances, but at the same time influenced most favorabIy the prognosis. The most important point in using radium is to appIy it earIy and in doses which consist of four appIications, eight hours in duration, at intervaIs of eight hours, of four 50 mg. tubes. The care of the postoperative wound foIIowing the second stage of the procedure is of importance and is best carried out by attendants who are accustomed to handIing such cases. For the first seventy-two hours the wound is untouched except for changing the outside dressings. There wiI1 be a smaI1 amount of serosanguinous drainage, but not a great dea1. At the end of seventy-two hours it is desirabIe to remove the gauze pack and begin hot irrigations. The gauze pack is removed after carefuIIy soaking it with peroxide of hydrogen, and pain may be done away with by the administration of some of the barbiturates. Two irrigations a day are generaIIy empIoyed after remova of the pack, of either a physioIogica1 soIution of sodium chIoride or a soIution of potassium permanganate I :5000. Irrigations are aIso suppIemented by heat from an arc of carbon filament Iamp which is empIoyed twice daiIy. It is astounding how few of these wounds deveIop severe infections, and how readiIy most of them hea up. UsuaIIy it is a matter of two or three months before they are entireIy heaIed, but I have seen one instance in which the posterior wound had heaIed, except a smaI1 superficia1 granuIating surface, by the end of the twenty-seventh day.
CANCER OF RECTOSIGMOID AND RECTUM
-yi
The care of the coIostomy is an important consideration and is handicapped rather than advantaged by the use of any compIicated or combersome bag or attachment to receive the feca1 materia1 from the stoma. Since abandoning a11 such apparatus and reIying upon a simpIe eIastic beIt which is much Iike an ordinary abdomina1 supporter, and in which is pIaced a removabIe rubber mat about 8 inches square, I have found that these patients are much more comfortabIe. They cIeanse and irrigate the bowe1 once a day, pIace a smaI1 amount of cotton or tissue paper over the stoma, and over this appIy the simpIe beIt. So Iong as the stooIs are formed there is scant IikeIihood of unpIeasant accidents except for the escape of gases. When the boweIs are Ioose, any coIostomy is intoIerabIe and no type of apparatus is satisfactory. The menta1 attitude of the patient toward the care of his coIostomy, and attention to his diet, are important factors in his comfort. The uItimate end-resuIts foIIowing successfu1 extirpation of maIignancies of the rectum by radica1 means have been proved by statistica studies of a Iong series of cases by man? surgeons. Whether the operative type of procedure can be accompIished in one stage or two, I think, depends upon a great many factors, but the probIem of greatest importance is to adjust operative technique to the whoIe group of cases in such a manner that each individual will receive the best chance of Iongevity by utilizing the maneuver most suitabIe for the individua1 case. That no routine measure is adaptabIe to aII, seems obvious. I beIieve that procedures which are compatibIe with a mortahty rate of around IO per cent shouId be instituted in every case as judgment indicates. That there shouId not be a marked Iowering in the operabiIity curve seems most essentia1. The very fact that 46 per cent of the removed specimens show gIanduIar invoIvement seems adequate reason for appIying a maneuver to cancers of the rectum and rectosigmoid which wiI1 extend the operative &Id beyond the IocaI growth and the first group of glands in immediate juxtaposition to it.