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Anterior Resection for Carcinoma of the Lower Portion of Sigmoid, the Rectosigmoid and the Upper Portion of Rectum: Present Status
Anterior Resection for Carcinoma of the Lower Portion of Sigmoid, the Rectosigmoid and the Upper Portion of Rectum: Present Status CHARLES W. MAYO
THE lesions with which I am concerned are those whose lower borders lie in the portion of bowel from 6 through 14 cm. above the dentate margin of the anus, as measured at proctoscopic examination. I have included also some data on those situated from 0 through 5 cm. and from 15 through 24 cm. There was a time when those who dared to write or talk in support of sphincter-preserving operations for malignant lesions situated within these anatomic confines were torn apart, figuratively speaking. And it must be confessed that those who went against the current of technical opinion to advocate such operations for these lesions did so with little or no support from the published reports of past experience or from the great majority of the most eminent surgeons who specialized in rectal and colonic diseases. The established dictum was simply that the procedure to be performed for malignant lesions in this location, as well as for those in the anus and up to 6 cm. from the anus, was combined abdominoperineal resection in single or multiple stages. Between these two techniques the one-stage combined abdominoperineal resection eventually became the choice-and, I believe, with statistical justification, in the absence of reliable proof that there was a place for sphincterpreserving operations for growths in this segment of bowel. Evidence now collected, however, indicates that certain concepts should be re-examined to determine the type of operation that offers the best result in an individual case of carcinoma located within the limits given. STATISTICAL COMPARISONS
Materials
Employment of Operations. In order to assure correct conclusions from a comparative study of the techniques of operation for such lesions, I 9S1
982
Charles W. Mayo
have set certain standards to determine the material for the analysis and the method of it: 1. The lower border of the lesion must lie within 25 cm. of the anus, as determined at proctoscopic examination. 2. The series must be of consecutive cases. 3. There must be a significant number of cases. 4. The operations must have been performed by several surgeons, not by just one. In cooperation with Dr. O. A. Fly a survey was made of all cases at the Mayo Clinic in which operations were performed for carcinoma in the designated portion of the bowel in the years 1945 through 1949. Mter exclusion of those cases in which the surgeon considered the operation to be palliative at the time of resection and (because of the difficulty of follow-up) the cases of foreign residents, there remained 1146 cases for analysis. As a basis for comparison of three types of resectional technique, this series afforded 319 instances of anterior resection (both with and without colostomy), 612 of one-stage combined abdominoperineal resection, and 215 of two-stage combined abdominoperineal resection. In each group the number seemed enough to bear significance. In 1951, with Lee and Davis, I analyzed this same series of cases (but prior to the exclusions mentioned above) from the standpoints of surgical mortality and of morbidity, and demonstrated that surgical mortality did not differ significantly after any of the three types of resection but that multiple-stage operations increased the morbidity significantly. To illustrate, low anterior resection with concomitant colostomy required an average of 30 days' hospitalization beyond that required for one-stage anterior resection without colostomy. If the additional time and expense could be justified by a lowering of the mortality rate it would seem reasonable to accept them. (I am not impressed by the justification on the basis of obstruction, as I have only as the rarest exception performed colostomy concomitantly with any low anterior resection; primary resection and end-to-end anastomosis plus dilatation of the anus are the substitute for colostomy.) Five-year Survival. It was of great interest to me when after the necessary waiting period the Section of Biometry and Medical Statistics of the Clinic provided a 98.7 per cent five-year follow-up, to compare the figures on five-year survival after each of the three principal types of resection. Exclusion of hospital deaths had left the number of cases at 1104, and 1090 of these had been traced. The fact that the survival rate was the same after anterior resections with or without colostomy made possible the combining of these two subdivisions to keep the number significant. Lesions 0 Through 5 CIll. frolll the Anal Margin
Understandably, material for a full comparison of results from the several techniques was not available at all levels. The operation of
Anterior Resection of Sigmoid, Rectosigmoid and Rectum
983
choice for malignant lesions which lie below a line 6 cm. from the dentate margin is one-stage combined abdominoperineal resection, and it is only as a rare exception that anterior resection should be attempted with view to cure for lesions thus situated; in this series of cases it was employed only three times. The belief that malignant lesions in the last 5 cm. of rectum have the poorest prognosis is widespread, but the findings in this series did not support it. In 254 cases in which one-stage combined abdominoperineal resection was performed, 50.4 per cent of the patients survived five years or longer, regardless of the presence or absence of metastasis at the time of operation. Among cases in which metastasis was not found, the survival rate was about 68 per cent, and under the same condition the rate did not vary significantly from this among cases in which lesions were situated 6 through 9 cm. or 10 through 14 cm. from the anal margin. In the 85 cases in which two-stage combined abdominoperineal resection was performed for lesions less than 6 cm. from the anal margin with and without metastasis, the five-year survival rate was not so favorable as that in cases of one-stage operations, and this discrepancy cannot be accounted for on the basis that the multiple-stage operations are reserved for the more advanced lesions. Lesions 6 Through 9 Clll. frolll the Anal Margin
In this next portion of the bowel the rates of survival after anterior resection and those after combined abdominoperineal resection can be compared. Among the traced cases in which the lower edge of the lesion lay from 6 cm. through 9 cm. from the dentate margin, there were 63 low anterior resections after which the five-year survival rate was 50.8 per cent, as compared with 219 one-stage combined abdominoperineal resections after which the five-year survival rate was 54.8 per cent, and with 86 two-stage combined abdominoperineal resections after which the five-year survival rate was 50 per cent. Although there is a difference of 4 per cent in favor of the one-stage combined abdominoperineal resections, what patient would not accept this risk to avoid permanent colostomy? I will have more to say about the lesions at this level, from the standpoint of surgical technique. Lesions 10 Through 14 Clll. and More frolll the Anal Margin
For lesions situated 10 to 14 cm. from the dentate margin of the anus, the five-year survival begins to show a trend away from either the onestage or the two-stage combined abdominoperineal resection, in favor of low anterior resection. In this group were 212 traced patients who had undergone low anterior resection. The five-year survival rate for this group was 61.3 per cent; there were 98 one-stage combined abdominoperineal resections after which the five-year survival rate was 48 per
984
Charles W. Mayo
cent, and 38 two-stage combined abdominoperineal resections after which the five-year survival rate was 39.5 per cent. As for the possible argument that the combined types of procedures have been reserved for the worst cases, the practice at the Clinic for the last few years has been to consider obesity almost the only obstacle to anterior resection with end-to-end coloproctostomy for any lesion situated 6 cm. or more from the dentate margin of the anus. (In the performance of low anterior resection, the abdominal part of the operation is carried out as is the abdominal part of the one-stage combined abdominoperineal resection.) At the Mayo Clinic, malignant lesions whose lower limit lies 15 cm. from the dentate margin or higher are dealt with, except rarely, by some form of anterior resection, usually a one-stage procedure with end-to-end anastomosis. TECHNIQUE OF ANTERIOR RESECTION IN THE 6 THROUGH 9 CM. ZONE
1 will restrict my remaining consideration of anterior resection with end-to-end coloproctostomy to the employment and technique of it in the most controversial portion of the bowel, that measuring from 6 through 9 cm. from the dentate margin. To compare the frequency of employment of the three established operative procedures, 1 revert to the series of cases as delimited prior to the exclusion of hospital deaths and losses in follow-up. For lesions situated 6 through 9 cm. from the dentate margin, 68 anterior resections, 234 one-stage combined abdominoperineal resections, and 90 multiplestage combined abdominoperineal resections were performed. For lesions situated 10 through 14 cm. from the dentate margin, the numbers practically reversed themselves, in that 224 anterior resections, 105 one-stage combined abdominoperineal resections, and 38 two-stage combined abdominoperineal resections were performed. Some explanation of this is needed, particularly in view of the fact that the five-year survival rates varied little after operations for lesions at the two levels. The question as to why the sphincter-preserving anterior resection is not used for more patients who have lesions 6 to 9 cm. above the dentate margin can be answered on the basis of technical difficulty. With this in mind, some years ago 1 determined that the first requirement for overcoming the handicap was to have surgical instruments made of proper length and shape to enable me to work in the deep region where it is necessary to join the sigmoid and rectum. (1 work through a right rectus horizontal incision, retracting the rectus muscle laterally.) The V. Mueller Company cooperated in producing the instruments (Fig. 271). It is prerequisite to any accurate joining of the ends of the transected sigmoid and rectum at this depth that the surgeon be able to cut across
~ ~
~
~. "'!
l;:Ij ~ ~ .,.., ~. ~
.s, V:l
~.
c J~.~ l;:Ij ~
SCI> ~. C
~
R l;:Ij ~
[ Fig. 271. From top to bottom: (1) long fingers for holding tissue deep in the pelvis; (2) long needle holder; (3) long scissors with a slightly curved end; (4) retractor for the bladder or the uterus; (5) angulated clamp, the angle of the blade being obtuse and not a right angle. The clamp is placed at the point of transection of the rectum below the growth.
<:c
~
986
Charles W. Mayo
the rectum 1 inch (2.5 cm. )j>E)!()":' th~lesion, the lower border of which may be as little as 6 cm. above the dentate margin. It can be done if the rectum and perirectal tissue are properly dissected from above, and an especially designed clamp can be placed across the rectum below the growth. No clamp can be used, however, on the severed distal portion of rectum. Whatever the calculated risk of seeding of cancer cells is, that risk must be taken. It is my opinion, based on the rate of five-year survival after low anterior resection, in which some soiling inevitably takes place, and on the rate of five-year survival after one-stage combined abdominoperineal rese~tion, in which soiling rarely takes place, that the factor of seeding is overemphasized, and at present I would consider any so-called recurrence rather to be due to residual carcinoma. In order to avoid this latter occurrence, it is well to have a competent pathologist study the proximal edge of the transected rectum by frozen section for submucosal spread of the malignant lesion before the anastomosis is completed. If the pathologic findings indicate the necessity, the operation can be transformed from anterior resection to one-stage combined abdominoperineal resection. If, however, the growth is not lower than 6 cm. from the dentate margin, low anterior resection is usually possible except, as said before, in the grossly obese patient. The end of the transected sigmoid lies outside the abdominal incision, where it has been stabilized by a small curved clamp which affixes an epiploic tag to a "salt" (surgical laparotomy pads soaked in saline solution) to keep the bowel from slipping back into the abdominal cavity. The clamp is removed, and the sigmoidal lumen is explored with a finger to make sure that there is no remaining polyp near the site where the anastomosis will be made. When this part of the procedure is' completed, anastomosis should be started. There are three essential points to remember when the anastomosis is performed: (1) it must be made without tension; (2) no running nonabsorbable sutures should be used, and (3) it must be accurate. The center·pQsterior suture is placed first. This single cotton suture is placed in the muscular coat of the cut edge of the rectal stump and then in the mesenteric side of the outer coat of the transected proximal barrel of sigmoid. This stitch is left long and is clamped. Three similar lone single cotton sutures are placed on each side of it, spaced around the posterior 180 degrees of the sigmoid, and these likewise are left long and clamped. The seven long interrupted cotton sutures are placed in order over the hands of the surgeon and of the first assistant; the sutures are drawn moderately taut and then, with them serving as guy ropes, the upper barrel of bowel is gently worked down into position at. the posterior edge of the rectum by means of gauze held by long surgical forceps called "fingers. " The interrupted cotton sutures are tied next; the two extreme lateral
Anterior Resection of Sigmoid, Rectosigmoid and Rectum
987
sutures and the center one are left long to aid in placing the mucosal row of running fine catgut suture of size 0 or 00. This catgut is about 36 inches long and is fixed on a needle. The mucosa of the posterior half circle is closed by a running through-and-through stitch, and that of the anterior arc is closed with a baseball stitch which catches the edge of the outer coat, runs along the submucosa and catches the edge of the mucosa, and then goes to the other side; this is repeated along the length of the opening. The anterior outer coat then is closed with multiple interrupted cotton sutures. Should there be oozing of blood in the sacral region, it is swabbed with an antiseptic and a clotting agent is used. (I use gelfoam.) I drain with one or two small Penrose rubber drains, bringing them out of the lower angle of the abdominal incision. Before closing the incision, I extraperitonealize the line of anastomosis in the pelvis. On my surgical service, as experience has taught, we do not perform either a preliminary or a concomitant colostomy, nor do we use a MillerAbbott tube routinely. We do dilate the anus before we take the patient off the operating table. We have one big postoperative "don't"; namely, don't insert anything into the rectum, not even an examining finger, no matter how tempted, because for many days an anastomosis is too easily separated. Ordinarily the patient may sit on the edge of the bed the day after operation, and we encourage activity. The usual period of hospitalization is two weeks. COMMENT AND CONCLUSION
The operation of low anterior resection in one stage with end-to-end anastomosis (sigmoidoproctostomy) is possible for the vast majority of malignant lesions lying in the rectum from 6 cm. through 9 cm. from the dentate margin or higher. Concomitant colostomy usually is not necessary. The anus and anal control can be preserved with low morbidity, low hospital mortality, favorably comparable five-year or longer survival, and no greater so-called recurrence rate than that found in similar cases in which one-stage combined abdominoperineal resection has been performed. It now appears that the combined abdominoperineal resection, with rare exception, can be reserved for malignant lesions of the anus and that portion of the rectum less than 6 cm. from the anal margin. While I do so with some reserve, I am willing at this time to state that with proper preparation of the patient, with the present therapeutic armamentarium at hand, and with the proper instruments for the work, multiple-stage operations almost never need be done.
THE lesions with which I am concerned are those whose lower borders lie in the portion of bowel from 6 through 14 cm. above the dentate margin of the anus, as measured at proctoscopic examination. I have included also some data on those situated from 0 through 5 cm. and from 15 through 24 cm. There was a time when those who dared to write or talk in support of sphincter-preserving operations for malignant lesions situated within these anatomic confines were torn apart, figuratively speaking. And it must be confessed that those who went against the current of technical opinion to advocate such operations for these lesions did so with little or no support from the published reports of past experience or from the great majority of the most eminent surgeons who specialized in rectal and colonic diseases. The established dictum was simply that the procedure to be performed for malignant lesions in this location, as well as for those in the anus and up to 6 cm. from the anus, was combined abdominoperineal resection in single or multiple stages. Between these two techniques the one-stage combined abdominoperineal resection eventually became the choice-and, I believe, with statistical justification, in the absence of reliable proof that there was a place for sphincterpreserving operations for growths in this segment of bowel. Evidence now collected, however, indicates that certain concepts should be re-examined to determine the type of operation that offers the best result in an individual case of carcinoma located within the limits given. STATISTICAL COMPARISONS
Materials
Employment of Operations. In order to assure correct conclusions from a comparative study of the techniques of operation for such lesions, I 9S1
982
Charles W. Mayo
have set certain standards to determine the material for the analysis and the method of it: 1. The lower border of the lesion must lie within 25 cm. of the anus, as determined at proctoscopic examination. 2. The series must be of consecutive cases. 3. There must be a significant number of cases. 4. The operations must have been performed by several surgeons, not by just one. In cooperation with Dr. O. A. Fly a survey was made of all cases at the Mayo Clinic in which operations were performed for carcinoma in the designated portion of the bowel in the years 1945 through 1949. Mter exclusion of those cases in which the surgeon considered the operation to be palliative at the time of resection and (because of the difficulty of follow-up) the cases of foreign residents, there remained 1146 cases for analysis. As a basis for comparison of three types of resectional technique, this series afforded 319 instances of anterior resection (both with and without colostomy), 612 of one-stage combined abdominoperineal resection, and 215 of two-stage combined abdominoperineal resection. In each group the number seemed enough to bear significance. In 1951, with Lee and Davis, I analyzed this same series of cases (but prior to the exclusions mentioned above) from the standpoints of surgical mortality and of morbidity, and demonstrated that surgical mortality did not differ significantly after any of the three types of resection but that multiple-stage operations increased the morbidity significantly. To illustrate, low anterior resection with concomitant colostomy required an average of 30 days' hospitalization beyond that required for one-stage anterior resection without colostomy. If the additional time and expense could be justified by a lowering of the mortality rate it would seem reasonable to accept them. (I am not impressed by the justification on the basis of obstruction, as I have only as the rarest exception performed colostomy concomitantly with any low anterior resection; primary resection and end-to-end anastomosis plus dilatation of the anus are the substitute for colostomy.) Five-year Survival. It was of great interest to me when after the necessary waiting period the Section of Biometry and Medical Statistics of the Clinic provided a 98.7 per cent five-year follow-up, to compare the figures on five-year survival after each of the three principal types of resection. Exclusion of hospital deaths had left the number of cases at 1104, and 1090 of these had been traced. The fact that the survival rate was the same after anterior resections with or without colostomy made possible the combining of these two subdivisions to keep the number significant. Lesions 0 Through 5 CIll. frolll the Anal Margin
Understandably, material for a full comparison of results from the several techniques was not available at all levels. The operation of
Anterior Resection of Sigmoid, Rectosigmoid and Rectum
983
choice for malignant lesions which lie below a line 6 cm. from the dentate margin is one-stage combined abdominoperineal resection, and it is only as a rare exception that anterior resection should be attempted with view to cure for lesions thus situated; in this series of cases it was employed only three times. The belief that malignant lesions in the last 5 cm. of rectum have the poorest prognosis is widespread, but the findings in this series did not support it. In 254 cases in which one-stage combined abdominoperineal resection was performed, 50.4 per cent of the patients survived five years or longer, regardless of the presence or absence of metastasis at the time of operation. Among cases in which metastasis was not found, the survival rate was about 68 per cent, and under the same condition the rate did not vary significantly from this among cases in which lesions were situated 6 through 9 cm. or 10 through 14 cm. from the anal margin. In the 85 cases in which two-stage combined abdominoperineal resection was performed for lesions less than 6 cm. from the anal margin with and without metastasis, the five-year survival rate was not so favorable as that in cases of one-stage operations, and this discrepancy cannot be accounted for on the basis that the multiple-stage operations are reserved for the more advanced lesions. Lesions 6 Through 9 Clll. frolll the Anal Margin
In this next portion of the bowel the rates of survival after anterior resection and those after combined abdominoperineal resection can be compared. Among the traced cases in which the lower edge of the lesion lay from 6 cm. through 9 cm. from the dentate margin, there were 63 low anterior resections after which the five-year survival rate was 50.8 per cent, as compared with 219 one-stage combined abdominoperineal resections after which the five-year survival rate was 54.8 per cent, and with 86 two-stage combined abdominoperineal resections after which the five-year survival rate was 50 per cent. Although there is a difference of 4 per cent in favor of the one-stage combined abdominoperineal resections, what patient would not accept this risk to avoid permanent colostomy? I will have more to say about the lesions at this level, from the standpoint of surgical technique. Lesions 10 Through 14 Clll. and More frolll the Anal Margin
For lesions situated 10 to 14 cm. from the dentate margin of the anus, the five-year survival begins to show a trend away from either the onestage or the two-stage combined abdominoperineal resection, in favor of low anterior resection. In this group were 212 traced patients who had undergone low anterior resection. The five-year survival rate for this group was 61.3 per cent; there were 98 one-stage combined abdominoperineal resections after which the five-year survival rate was 48 per
984
Charles W. Mayo
cent, and 38 two-stage combined abdominoperineal resections after which the five-year survival rate was 39.5 per cent. As for the possible argument that the combined types of procedures have been reserved for the worst cases, the practice at the Clinic for the last few years has been to consider obesity almost the only obstacle to anterior resection with end-to-end coloproctostomy for any lesion situated 6 cm. or more from the dentate margin of the anus. (In the performance of low anterior resection, the abdominal part of the operation is carried out as is the abdominal part of the one-stage combined abdominoperineal resection.) At the Mayo Clinic, malignant lesions whose lower limit lies 15 cm. from the dentate margin or higher are dealt with, except rarely, by some form of anterior resection, usually a one-stage procedure with end-to-end anastomosis. TECHNIQUE OF ANTERIOR RESECTION IN THE 6 THROUGH 9 CM. ZONE
1 will restrict my remaining consideration of anterior resection with end-to-end coloproctostomy to the employment and technique of it in the most controversial portion of the bowel, that measuring from 6 through 9 cm. from the dentate margin. To compare the frequency of employment of the three established operative procedures, 1 revert to the series of cases as delimited prior to the exclusion of hospital deaths and losses in follow-up. For lesions situated 6 through 9 cm. from the dentate margin, 68 anterior resections, 234 one-stage combined abdominoperineal resections, and 90 multiplestage combined abdominoperineal resections were performed. For lesions situated 10 through 14 cm. from the dentate margin, the numbers practically reversed themselves, in that 224 anterior resections, 105 one-stage combined abdominoperineal resections, and 38 two-stage combined abdominoperineal resections were performed. Some explanation of this is needed, particularly in view of the fact that the five-year survival rates varied little after operations for lesions at the two levels. The question as to why the sphincter-preserving anterior resection is not used for more patients who have lesions 6 to 9 cm. above the dentate margin can be answered on the basis of technical difficulty. With this in mind, some years ago 1 determined that the first requirement for overcoming the handicap was to have surgical instruments made of proper length and shape to enable me to work in the deep region where it is necessary to join the sigmoid and rectum. (1 work through a right rectus horizontal incision, retracting the rectus muscle laterally.) The V. Mueller Company cooperated in producing the instruments (Fig. 271). It is prerequisite to any accurate joining of the ends of the transected sigmoid and rectum at this depth that the surgeon be able to cut across
~ ~
~
~. "'!
l;:Ij ~ ~ .,.., ~. ~
.s, V:l
~.
c J~.~ l;:Ij ~
SCI> ~. C
~
R l;:Ij ~
[ Fig. 271. From top to bottom: (1) long fingers for holding tissue deep in the pelvis; (2) long needle holder; (3) long scissors with a slightly curved end; (4) retractor for the bladder or the uterus; (5) angulated clamp, the angle of the blade being obtuse and not a right angle. The clamp is placed at the point of transection of the rectum below the growth.
<:c
~
986
Charles W. Mayo
the rectum 1 inch (2.5 cm. )j>E)!()":' th~lesion, the lower border of which may be as little as 6 cm. above the dentate margin. It can be done if the rectum and perirectal tissue are properly dissected from above, and an especially designed clamp can be placed across the rectum below the growth. No clamp can be used, however, on the severed distal portion of rectum. Whatever the calculated risk of seeding of cancer cells is, that risk must be taken. It is my opinion, based on the rate of five-year survival after low anterior resection, in which some soiling inevitably takes place, and on the rate of five-year survival after one-stage combined abdominoperineal rese~tion, in which soiling rarely takes place, that the factor of seeding is overemphasized, and at present I would consider any so-called recurrence rather to be due to residual carcinoma. In order to avoid this latter occurrence, it is well to have a competent pathologist study the proximal edge of the transected rectum by frozen section for submucosal spread of the malignant lesion before the anastomosis is completed. If the pathologic findings indicate the necessity, the operation can be transformed from anterior resection to one-stage combined abdominoperineal resection. If, however, the growth is not lower than 6 cm. from the dentate margin, low anterior resection is usually possible except, as said before, in the grossly obese patient. The end of the transected sigmoid lies outside the abdominal incision, where it has been stabilized by a small curved clamp which affixes an epiploic tag to a "salt" (surgical laparotomy pads soaked in saline solution) to keep the bowel from slipping back into the abdominal cavity. The clamp is removed, and the sigmoidal lumen is explored with a finger to make sure that there is no remaining polyp near the site where the anastomosis will be made. When this part of the procedure is' completed, anastomosis should be started. There are three essential points to remember when the anastomosis is performed: (1) it must be made without tension; (2) no running nonabsorbable sutures should be used, and (3) it must be accurate. The center·pQsterior suture is placed first. This single cotton suture is placed in the muscular coat of the cut edge of the rectal stump and then in the mesenteric side of the outer coat of the transected proximal barrel of sigmoid. This stitch is left long and is clamped. Three similar lone single cotton sutures are placed on each side of it, spaced around the posterior 180 degrees of the sigmoid, and these likewise are left long and clamped. The seven long interrupted cotton sutures are placed in order over the hands of the surgeon and of the first assistant; the sutures are drawn moderately taut and then, with them serving as guy ropes, the upper barrel of bowel is gently worked down into position at. the posterior edge of the rectum by means of gauze held by long surgical forceps called "fingers. " The interrupted cotton sutures are tied next; the two extreme lateral
Anterior Resection of Sigmoid, Rectosigmoid and Rectum
987
sutures and the center one are left long to aid in placing the mucosal row of running fine catgut suture of size 0 or 00. This catgut is about 36 inches long and is fixed on a needle. The mucosa of the posterior half circle is closed by a running through-and-through stitch, and that of the anterior arc is closed with a baseball stitch which catches the edge of the outer coat, runs along the submucosa and catches the edge of the mucosa, and then goes to the other side; this is repeated along the length of the opening. The anterior outer coat then is closed with multiple interrupted cotton sutures. Should there be oozing of blood in the sacral region, it is swabbed with an antiseptic and a clotting agent is used. (I use gelfoam.) I drain with one or two small Penrose rubber drains, bringing them out of the lower angle of the abdominal incision. Before closing the incision, I extraperitonealize the line of anastomosis in the pelvis. On my surgical service, as experience has taught, we do not perform either a preliminary or a concomitant colostomy, nor do we use a MillerAbbott tube routinely. We do dilate the anus before we take the patient off the operating table. We have one big postoperative "don't"; namely, don't insert anything into the rectum, not even an examining finger, no matter how tempted, because for many days an anastomosis is too easily separated. Ordinarily the patient may sit on the edge of the bed the day after operation, and we encourage activity. The usual period of hospitalization is two weeks. COMMENT AND CONCLUSION
The operation of low anterior resection in one stage with end-to-end anastomosis (sigmoidoproctostomy) is possible for the vast majority of malignant lesions lying in the rectum from 6 cm. through 9 cm. from the dentate margin or higher. Concomitant colostomy usually is not necessary. The anus and anal control can be preserved with low morbidity, low hospital mortality, favorably comparable five-year or longer survival, and no greater so-called recurrence rate than that found in similar cases in which one-stage combined abdominoperineal resection has been performed. It now appears that the combined abdominoperineal resection, with rare exception, can be reserved for malignant lesions of the anus and that portion of the rectum less than 6 cm. from the anal margin. While I do so with some reserve, I am willing at this time to state that with proper preparation of the patient, with the present therapeutic armamentarium at hand, and with the proper instruments for the work, multiple-stage operations almost never need be done.