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Selective surgery in operable rectal cancer
SELECTIVE SURGERY IN OPERABLE RECTAL CANCER* GEORGE E. BINKLEY,M.B.(ToR.) NEW
YORK
T
cipient stages, treatment wouId be greatIy simpIified and exceIIent resuIts obtained by the majority of the above methods of procedure. UnfortunateIy, many operabIe Iesions are we11 estabIished, often with invoIvment of the Iymphatic and the adjacent tissues, at the time patients come under observation. As a ruIe, the extent of the disease has a marked bearing upon the prognosis, which, however, may be favorabIy influenced in certain instances, when the disease is no Ionger IocaIized, by empIoyment of more radica1 forms of surgery. The abiIity of patients to withstand operation shouId be carefuIIy considered. Certain types of resection are accompanied by greater degrees of shock and more severe compIications than others. In most instances in the treatment of cancer in this Iocation, it is advisable to empIoy the most radica1 dissection that the patient appears abIe to withstand, as one is never sure of the extent of the disease. The probIem of seIecting treatment is. a comparativeIy simpIe one when dealing with patients in good physica condition. Unfortunately, recta1 cancer frequentIy occurs in patients of mature and oId age. Many of these patients are aIso victims of heart, Iung, kidnejr, metabohc or othir chronic diseases, factors which increase the hazards of successfu1 resection. It is impossibIe to treat recta1 cancer adequateIy without a certain percentage of operabIe fataIities. The Iatter, however, may be heId at a reasonabIy Iow figure by attempting to keep the treatment within the toIerance of the patient and at the same time to afford him the benefit of the most radica1 resection that he is abIe to withstand. OperabIe mortaIity, in a11 types of resections, has been Iessened by more carefu1 preoperative
HE treatment of recta1 cancer is an interesting but intricate probIem. Extirpation of the rectum has been practiced since Lisfranc reported his successfuI operation in 1926, but during the past quarter of a century there has been a marked improvement in the surgica1 treatment of this disease. New types of operative procedures have been described, and the surgica1 technique of recta1 resections has been greatIy improved. Despite these improvements, there is not, as yet, any one procedure that is suitabIe for routine empioyment in a11 cases. Two factors, (I) the variation in the extent of disease at the time patients are referred for treatment, and (2) the variation in the abiIity of patients to withstand radica1 resection, make selective surgery preferabIe to the routine use of any one method. The types of operation that have proven of greatest vaIue and appear worthy of consideration in seIecting treatment for operable diseases, are: (I) abdomino-perinea1 resections compIeted in one or two stages; and (2) perinea1 resections with or without preIiminary coIostomy. Each of the above procedures has a fieId of usefuIness in the surgica1 treatment of this disease. Most appropriate seIection can be made from the knowledge of the comparative advantages and Iimitations of each procedure, the pathoIogic factors of the disease presented, and the genera1 physica condition and the psychoIogy of the patient. EarIy diagnosis is the greatest asset to successful treatment regardIess of the method empIoyed. Recta1 cancer begins as a IocaI disease in the mucosa and extends both by direct continuity of the disease and by dissemination through the Iymphatic and bIood streams. If it were possibIe, uniformIy, to recognize cancer in the earIy in* Read before
CITY
the American ProctoIogic Society, at AtIantic City, June 1937. 51
52
American
Journal
of Surgery
Binkley-Rectal
preparation, by IiberaI empIoyment of blood transfusions, better surgery and more detaiIed after treatment. By obtaining a carefu1 history and by detaiIed physica and Iaboratory investigations, the surgeon may estimate the patient’s abiIity to withstand operation to a rather accurate workabIe degree. In accordance with these investigations, patients with operabIe disease may be separated into four groups, (I) good, (2) medium, (3) poor, and (4) bad surgica1 risks. AIthough the primary disease may be removabIe in patients cIassified as bad risks, the poor physica condition contraindicates the empIoyment of radica1 surgery. Location of the tumor may aIso, at times, infhrence the seIection of surgica1 treatment. The term, recta1 cancer, frequentIy incIudes Iesions situated anywhere from the anus to the rectosigmoidal junction. Low Iesions, within reach of the index hnger, may or may not be suitabIe for perineaI extirpation, depending upon the extent of the disease and condition of the patient. The most appropriate approach for tumors in the upper rectum and at the rectosigmoida1 junction is by way of the abdomino-perinea1 route, unIess this form of surgery is contraindicated by the patient’s poor physicaI condition. Abdomino-perinea1 resection is the idea1 surgica1 method of approach in eradicating rectal and rectosigmoida1 cancers. This type of operation permits remova of the primary tumor with a wide dissection of adjacent tissues and Iymph-drained areas. The terminal intestina1 tract from the middIe of the sigmoid to the anus is aIso removed. The patient retains a permanent coIostomy. Abdomino-perinea1 operations may be compIeted at one time as advocated by MiIes, or the dissection may be in two stages as suggested by Coffey, Rankin, Lahey and others. The choice between the one- and the two-stage procedures rests IargeIy upon the genera1 physical condition of the patient, the degree of obstruction, the degree of infection and the extent of the disease.
Cancer The one-stage or MiIes’ type of procedure has the advantage of being compIeted at one time. Patients are immediateIy reIieved of the worries and fears of a second operation. ConvaIescence, if uncompIicated, is short, and the majority of patients Ieave the hospita1 within four weeks. The chief objection to the one-stage procedure, when it is routineIy empIoyed, is the accompanying high operative mortaIity. MiIes, however, has shown that the mortaIity from his operation may be kept comparativeIy Iow by seIecting suitabIe cases. Experience in the seIection of cases and improvement in surgica1 technique tend to increase the popuIarity of the one-stage operation. Two-stage abdomino-perinea1 resections have been devised to accompIish with a comparativeIy Iower operabIe mortaIity a simiIar dissection to that afforded by the MiIes operation. Of the two-stage procedures that have been described, the Lahey technique has received the greatest popuIarity. This operation appears to offer certain advantages over other two-stage procedures. The main objectionabIe features of this resection, outside of the inevitabIe two procedures, are (I) reopening the abdomen at the site of an intestina1 stoma, and (2) contending with adhesions which, at times, foIIow the first procedure. Despite these objectionable features, operabIe mortaIity is quite low. Shock is seIdom severe, and fata peritonitis is reIativeIy rare. The technique, as described by Lahey and his staff, has been foIIowed in most of our cases. In a few instances, when deaIing with Iarge friabIe, borderIine operable Iesions at the rectosigmoida1 junction, in order to Iessen the IikeIihood of rupture into the bowe1 or tumor, we have modified the technique. The second operation is begun in the usua1 manner. After tying the superior hemorrhoida artery and loosening the rectum posteriorIy, the dissection is then compIeted from beIow and the tumor removed by the perinea1 route. The new peIvic Aoor is then constructed and the abdomina1 wound cIosed in the
NEW SERIESVar. XLIII, No. I
Bin kIey-Rectal
usual manner. This technique converts the second stage into the abdominoperineal abdomina1 type of procedure. Whether this variation in technique is of any value under such circumstances wiII require additionaI experience to estimate fully. Judging from a Iimited experience of fifty-six abdomino-perineal operations in which there was an operative mortaIity of 12.5 per cent, we think there is a definite fieId for both one- and two-stage procedures in the routine treatment of recta1 cancer. One-stage operations appear to be best suited for good surgica1 risks with earIy or moderateIy advanced lesions. Two-stage procedures are suitable for medium surgica1 risks and for that smaI1 group of patients cIass&ed as good risks with badly infected, stenosing, borderIine operabIe cancers. The percentage of clinical cures foIIowing these types of resections shouId be superior to that of restricted methods of surgery. Such results, however, wiI1 depend Iargely upon the extent of disease in those cases seIected for this method of treatment. When sufficient time has eiapsed to compare the ultimate resuIts of the oneand the two-stage abdomino-perinea1 operations, in a11 probabiIity such resuIts wiI1 vary more in accordance with the extent of disease at time of operation than with the method of procedure empIoyed. PERINEAL
RESECTIONS
Perineal resections are Iimited operations in that there is Iess opportunity for dissecting the areas drained by the Iymphatics than with the abdomina1 types of procedures. Limited dissections are capable of producing cIinica1 cures onIy when a11 cancer ceIIs can be removed. PerineaI resections, therefore, from the standpoint of obtaining cIinica1 cures, are best suited for cancers within the Iower haIf of the rectum in which the disease is we11 IocaIized. Such favorabIe conditions are encountered at times when the disease is recognized in the earI?- stages and when
Cancer
American
Journal
of Surgery
53
the histologic report reveals a low grade of maIignancy. The extensive routine empIoyment of perineal resection by many surgeons, as a method of eradicating recta1 cancer, has been due to the low operative mortaIity foIIowing this type of operation, and to the high operative mortaIity which accompanied abdomino-perinea1 resections a decade or more ago. Operative mortality from the perineal operation in our cIinic is Iess than 3 per cent. Because of this Iow mortaIity and despite its Iimited nature, this operation has a rea1 field of usefuIness in cases where patients in poor physica condition are quite unlikely to withstand more radica1 forms of surgery. The fina resuIts of perinea1 resections from most cIinics are Iess gratifying than those following resections, although abdomino-perinea1 Lockhart-Mummery, in a recent communication, gives figures which compare favorably with the most radical procedures. The Iow percentage of cIinica1 cures reported may be Iargely accounted for by the frequent empIoyment of this type of resection in advanced stages of disease. It is often empIoyed with borderIine and inoperabIe disease and with patients in poor physica condition, the objective being paIIiation rather than clinical cure. PerineaI resections are best reserved for that group of of old age and patients who, because chronic constitutiona disease, are considered poor surgica1 risks, and for the smaI1 percentage of patients with Iow-Iying tumors which stiI1 remain in the early stages of deveIopment. The rectum may be resected by the perineal route, with or without the constuction of a preIiminary abdomina1 colostomy. A prebminary operation permits expIoration of the abdomen to determine the presence or absence of metastatic disease, and pIaces the artificia1 anus in a convenient location for cIeanIiness and care. Preliminary CoIostomy often permits a wider dissection of the peIvis and the remova of Iarger sections of the rectum. The operative mortality is but IittIe
54
American Journal of Surgery
Binkley-Recta1
inffuenced by a preIiminary operation. PerineaI resections without coIostomy may be preferabIe when dealing with verv obese patients and those who absoIuteIy refuse to have an opening on the abdomina1 surface. PerineaI stomas function satisfactoriIy in the majority of instances, but they are Iess accessibIe for irrigations and cIeanIiness than those situated upon the abdomen. Operations that attempt continuity of bowe1 and sphincter contro1 have not proved to be very satisfactory in the treatment of recta1 cancer. Procedures such as IocaI excisions, perinea1 resections with preservation of the ana sphincter, and abdomina1 resections with anastomoses have been empIoyed in an effort to avoid a permanent art&a1 anus. We have had but Iittie experience in performing the above types of resection, but have seen many recurrences in patients subjected to these operations from other institutions. The chief objectionabIe feature to operations devised to avoid coIostomy is the high percentage of recurrences. Early recurrences are due to incomplete removal & “the cancer. Resections with continuity bf bowe1 and sphincter contro1 have a Iimited fieId, and are best reserved for ”
Cancer
JANUARY, 19x1
patients who absoIuteIy refuse to be operated upon if they are to retain a permanent coIostomy, and for a smaI1 percentage of earIy rectal and sigmoida1 cancers that are favorabIy situated for limited surgical dissections. In many instances of earIy recta1 cancer, eradication of the disease by radiation therapy which Ieaves the patient with a norma functioning intestina1 tract, is preferabIe to Iimited surgica1 resections. CONCLUSIONS
SeIective surgery in operabIe recta1 cancer is advisabIe because of variations in (I) the Iocation of Iesions, (2) the extent of disease, and (3) the physica condition of the patient. Abdomino-perineal resections, compIeted in one or two stages, afford the widest forms of dissection, and are preferabIe for the majority of patients who are cIassified as good and medium surgica1 risks. PerineaI resections, with or without preIiminary coIostomy, are best suited for tumors situated in the Iower two-thirds of the rectum in patients cIassified as poor surgica1 risks. Resections which attempt continuity of bowe1 and sphincter contro1 have but a Iimited field in present day surgica1 treatment of recta1 cancer.
YORK
T
cipient stages, treatment wouId be greatIy simpIified and exceIIent resuIts obtained by the majority of the above methods of procedure. UnfortunateIy, many operabIe Iesions are we11 estabIished, often with invoIvment of the Iymphatic and the adjacent tissues, at the time patients come under observation. As a ruIe, the extent of the disease has a marked bearing upon the prognosis, which, however, may be favorabIy influenced in certain instances, when the disease is no Ionger IocaIized, by empIoyment of more radica1 forms of surgery. The abiIity of patients to withstand operation shouId be carefuIIy considered. Certain types of resection are accompanied by greater degrees of shock and more severe compIications than others. In most instances in the treatment of cancer in this Iocation, it is advisable to empIoy the most radica1 dissection that the patient appears abIe to withstand, as one is never sure of the extent of the disease. The probIem of seIecting treatment is. a comparativeIy simpIe one when dealing with patients in good physica condition. Unfortunately, recta1 cancer frequentIy occurs in patients of mature and oId age. Many of these patients are aIso victims of heart, Iung, kidnejr, metabohc or othir chronic diseases, factors which increase the hazards of successfu1 resection. It is impossibIe to treat recta1 cancer adequateIy without a certain percentage of operabIe fataIities. The Iatter, however, may be heId at a reasonabIy Iow figure by attempting to keep the treatment within the toIerance of the patient and at the same time to afford him the benefit of the most radica1 resection that he is abIe to withstand. OperabIe mortaIity, in a11 types of resections, has been Iessened by more carefu1 preoperative
HE treatment of recta1 cancer is an interesting but intricate probIem. Extirpation of the rectum has been practiced since Lisfranc reported his successfuI operation in 1926, but during the past quarter of a century there has been a marked improvement in the surgica1 treatment of this disease. New types of operative procedures have been described, and the surgica1 technique of recta1 resections has been greatIy improved. Despite these improvements, there is not, as yet, any one procedure that is suitabIe for routine empioyment in a11 cases. Two factors, (I) the variation in the extent of disease at the time patients are referred for treatment, and (2) the variation in the abiIity of patients to withstand radica1 resection, make selective surgery preferabIe to the routine use of any one method. The types of operation that have proven of greatest vaIue and appear worthy of consideration in seIecting treatment for operable diseases, are: (I) abdomino-perinea1 resections compIeted in one or two stages; and (2) perinea1 resections with or without preIiminary coIostomy. Each of the above procedures has a fieId of usefuIness in the surgica1 treatment of this disease. Most appropriate seIection can be made from the knowledge of the comparative advantages and Iimitations of each procedure, the pathoIogic factors of the disease presented, and the genera1 physica condition and the psychoIogy of the patient. EarIy diagnosis is the greatest asset to successful treatment regardIess of the method empIoyed. Recta1 cancer begins as a IocaI disease in the mucosa and extends both by direct continuity of the disease and by dissemination through the Iymphatic and bIood streams. If it were possibIe, uniformIy, to recognize cancer in the earIy in* Read before
CITY
the American ProctoIogic Society, at AtIantic City, June 1937. 51
52
American
Journal
of Surgery
Binkley-Rectal
preparation, by IiberaI empIoyment of blood transfusions, better surgery and more detaiIed after treatment. By obtaining a carefu1 history and by detaiIed physica and Iaboratory investigations, the surgeon may estimate the patient’s abiIity to withstand operation to a rather accurate workabIe degree. In accordance with these investigations, patients with operabIe disease may be separated into four groups, (I) good, (2) medium, (3) poor, and (4) bad surgica1 risks. AIthough the primary disease may be removabIe in patients cIassified as bad risks, the poor physica condition contraindicates the empIoyment of radica1 surgery. Location of the tumor may aIso, at times, infhrence the seIection of surgica1 treatment. The term, recta1 cancer, frequentIy incIudes Iesions situated anywhere from the anus to the rectosigmoidal junction. Low Iesions, within reach of the index hnger, may or may not be suitabIe for perineaI extirpation, depending upon the extent of the disease and condition of the patient. The most appropriate approach for tumors in the upper rectum and at the rectosigmoida1 junction is by way of the abdomino-perinea1 route, unIess this form of surgery is contraindicated by the patient’s poor physicaI condition. Abdomino-perinea1 resection is the idea1 surgica1 method of approach in eradicating rectal and rectosigmoida1 cancers. This type of operation permits remova of the primary tumor with a wide dissection of adjacent tissues and Iymph-drained areas. The terminal intestina1 tract from the middIe of the sigmoid to the anus is aIso removed. The patient retains a permanent coIostomy. Abdomino-perinea1 operations may be compIeted at one time as advocated by MiIes, or the dissection may be in two stages as suggested by Coffey, Rankin, Lahey and others. The choice between the one- and the two-stage procedures rests IargeIy upon the genera1 physical condition of the patient, the degree of obstruction, the degree of infection and the extent of the disease.
Cancer The one-stage or MiIes’ type of procedure has the advantage of being compIeted at one time. Patients are immediateIy reIieved of the worries and fears of a second operation. ConvaIescence, if uncompIicated, is short, and the majority of patients Ieave the hospita1 within four weeks. The chief objection to the one-stage procedure, when it is routineIy empIoyed, is the accompanying high operative mortaIity. MiIes, however, has shown that the mortaIity from his operation may be kept comparativeIy Iow by seIecting suitabIe cases. Experience in the seIection of cases and improvement in surgica1 technique tend to increase the popuIarity of the one-stage operation. Two-stage abdomino-perinea1 resections have been devised to accompIish with a comparativeIy Iower operabIe mortaIity a simiIar dissection to that afforded by the MiIes operation. Of the two-stage procedures that have been described, the Lahey technique has received the greatest popuIarity. This operation appears to offer certain advantages over other two-stage procedures. The main objectionabIe features of this resection, outside of the inevitabIe two procedures, are (I) reopening the abdomen at the site of an intestina1 stoma, and (2) contending with adhesions which, at times, foIIow the first procedure. Despite these objectionable features, operabIe mortaIity is quite low. Shock is seIdom severe, and fata peritonitis is reIativeIy rare. The technique, as described by Lahey and his staff, has been foIIowed in most of our cases. In a few instances, when deaIing with Iarge friabIe, borderIine operable Iesions at the rectosigmoida1 junction, in order to Iessen the IikeIihood of rupture into the bowe1 or tumor, we have modified the technique. The second operation is begun in the usua1 manner. After tying the superior hemorrhoida artery and loosening the rectum posteriorIy, the dissection is then compIeted from beIow and the tumor removed by the perinea1 route. The new peIvic Aoor is then constructed and the abdomina1 wound cIosed in the
NEW SERIESVar. XLIII, No. I
Bin kIey-Rectal
usual manner. This technique converts the second stage into the abdominoperineal abdomina1 type of procedure. Whether this variation in technique is of any value under such circumstances wiII require additionaI experience to estimate fully. Judging from a Iimited experience of fifty-six abdomino-perineal operations in which there was an operative mortaIity of 12.5 per cent, we think there is a definite fieId for both one- and two-stage procedures in the routine treatment of recta1 cancer. One-stage operations appear to be best suited for good surgica1 risks with earIy or moderateIy advanced lesions. Two-stage procedures are suitable for medium surgica1 risks and for that smaI1 group of patients cIass&ed as good risks with badly infected, stenosing, borderIine operabIe cancers. The percentage of clinical cures foIIowing these types of resections shouId be superior to that of restricted methods of surgery. Such results, however, wiI1 depend Iargely upon the extent of disease in those cases seIected for this method of treatment. When sufficient time has eiapsed to compare the ultimate resuIts of the oneand the two-stage abdomino-perinea1 operations, in a11 probabiIity such resuIts wiI1 vary more in accordance with the extent of disease at time of operation than with the method of procedure empIoyed. PERINEAL
RESECTIONS
Perineal resections are Iimited operations in that there is Iess opportunity for dissecting the areas drained by the Iymphatics than with the abdomina1 types of procedures. Limited dissections are capable of producing cIinica1 cures onIy when a11 cancer ceIIs can be removed. PerineaI resections, therefore, from the standpoint of obtaining cIinica1 cures, are best suited for cancers within the Iower haIf of the rectum in which the disease is we11 IocaIized. Such favorabIe conditions are encountered at times when the disease is recognized in the earI?- stages and when
Cancer
American
Journal
of Surgery
53
the histologic report reveals a low grade of maIignancy. The extensive routine empIoyment of perineal resection by many surgeons, as a method of eradicating recta1 cancer, has been due to the low operative mortaIity foIIowing this type of operation, and to the high operative mortaIity which accompanied abdomino-perinea1 resections a decade or more ago. Operative mortality from the perineal operation in our cIinic is Iess than 3 per cent. Because of this Iow mortaIity and despite its Iimited nature, this operation has a rea1 field of usefuIness in cases where patients in poor physica condition are quite unlikely to withstand more radica1 forms of surgery. The fina resuIts of perinea1 resections from most cIinics are Iess gratifying than those following resections, although abdomino-perinea1 Lockhart-Mummery, in a recent communication, gives figures which compare favorably with the most radical procedures. The Iow percentage of cIinica1 cures reported may be Iargely accounted for by the frequent empIoyment of this type of resection in advanced stages of disease. It is often empIoyed with borderIine and inoperabIe disease and with patients in poor physica condition, the objective being paIIiation rather than clinical cure. PerineaI resections are best reserved for that group of of old age and patients who, because chronic constitutiona disease, are considered poor surgica1 risks, and for the smaI1 percentage of patients with Iow-Iying tumors which stiI1 remain in the early stages of deveIopment. The rectum may be resected by the perineal route, with or without the constuction of a preIiminary abdomina1 colostomy. A prebminary operation permits expIoration of the abdomen to determine the presence or absence of metastatic disease, and pIaces the artificia1 anus in a convenient location for cIeanIiness and care. Preliminary CoIostomy often permits a wider dissection of the peIvis and the remova of Iarger sections of the rectum. The operative mortality is but IittIe
54
American Journal of Surgery
Binkley-Recta1
inffuenced by a preIiminary operation. PerineaI resections without coIostomy may be preferabIe when dealing with verv obese patients and those who absoIuteIy refuse to have an opening on the abdomina1 surface. PerineaI stomas function satisfactoriIy in the majority of instances, but they are Iess accessibIe for irrigations and cIeanIiness than those situated upon the abdomen. Operations that attempt continuity of bowe1 and sphincter contro1 have not proved to be very satisfactory in the treatment of recta1 cancer. Procedures such as IocaI excisions, perinea1 resections with preservation of the ana sphincter, and abdomina1 resections with anastomoses have been empIoyed in an effort to avoid a permanent art&a1 anus. We have had but Iittie experience in performing the above types of resection, but have seen many recurrences in patients subjected to these operations from other institutions. The chief objectionabIe feature to operations devised to avoid coIostomy is the high percentage of recurrences. Early recurrences are due to incomplete removal & “the cancer. Resections with continuity bf bowe1 and sphincter contro1 have a Iimited fieId, and are best reserved for ”
Cancer
JANUARY, 19x1
patients who absoIuteIy refuse to be operated upon if they are to retain a permanent coIostomy, and for a smaI1 percentage of earIy rectal and sigmoida1 cancers that are favorabIy situated for limited surgical dissections. In many instances of earIy recta1 cancer, eradication of the disease by radiation therapy which Ieaves the patient with a norma functioning intestina1 tract, is preferabIe to Iimited surgica1 resections. CONCLUSIONS
SeIective surgery in operabIe recta1 cancer is advisabIe because of variations in (I) the Iocation of Iesions, (2) the extent of disease, and (3) the physica condition of the patient. Abdomino-perineal resections, compIeted in one or two stages, afford the widest forms of dissection, and are preferabIe for the majority of patients who are cIassified as good and medium surgica1 risks. PerineaI resections, with or without preIiminary coIostomy, are best suited for tumors situated in the Iower two-thirds of the rectum in patients cIassified as poor surgica1 risks. Resections which attempt continuity of bowe1 and sphincter contro1 have but a Iimited field in present day surgica1 treatment of recta1 cancer.