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Comparison of anterior and abdominoperineai resections for low pelvic colon and rectal carcinoma
Comparison
of Anterior
Abdominoperineal
Resections
Pelvic Colon and Rectal
and for Low
Carcinoma
ROGER D. WILLIAMS,M.D., ANTHONYA. YURKO, M.D., GRANT KERR, F.R.c.s., AND ROBERT M. ZOLLINGER,M.D., Columbus, Ohio
of patients at the University Hospital treated with anterior resection and abdominoperineal resection for carcinoma between 6 and 15 cm. from the anus suggests that anterior resection is the preferred procedure. This comparison includes location, size, and classification of the tumors, operative complications, mortality, fecal continence, and survival rates.
From the Defiartment of Surgery, The Ohio State University Hos@als, Columbus, Ohio.
Miles [1] proposed abdominoA LTHOUGH perineal resection as a more adequate operation for rectal cancer, more recent pathologic studies [Z-G] do not justify this radical procedure for all such carcinomas. The goal of surgery is to obtain the highest immediate and late survival with the fewest postoperative complications. Preservation of intestinal continuity would be ideal if the chance for cure were not jeopardized. In the area of the rectum below 6 cm. few surgeons would argue against total rectal and anal resection. The area between 6 and 15 cm., and especially between 6 and 12 cm., is controversial and has perhaps more advocates for abdominoperineal resection than for anterior resection with preservation of the sphincter. Comparison of nearly equal groups DUK?
NO. PATIENTS
rAEo-PER. IS ANT W6.14
MATERIAL Between January 1950 and December 1961, 182 of 830 carcinomas of the colon treated initially at the University Hospital were located between 6 and 15 cm. from the anus. The level of the tumor was determined by sigmoidoscopy. All lesions were also seen by barium enema, and a pathologic diagnosis was confirmed by biopsy. There were ninety-five men and eighty-seven women. Forty-nine women and thirty-nine men had anterior resection. The selection of the operative procedure was more often dependent upon the choice of the surgeon and the physical characteristics of the patient than tumor size, location, or local spread. Eighty-nine patients were treated by anterior resection, re-establishing colonic continuity, and ninety-three patients had abdominoperineal resection. In the latter group seventy-two (77.4 per cent) of the lesions were between 6 and 12 cm. while in 56.2 per cent of those in the former group the lesion was 12 to 15 cm. above the anus. Except for this difference in location, further analysis shows the groups nearly equal. As shown in Figure 1, the relative numbers of large lesions was comparable in the two groups and the median tumor size
CLf334FICZATl;N 32
34
II
32
27
I6
20
TUMOR SIZE (cm.) FIG. 1. Graphic representation of tumor size in 182 patients with carcinoma of the rectosigmoid. Based on tumor size and Duke’s classification the groups with anterior resection and abdominoperineal resection are comparable. 114
American Journal of Surgery
Resections
for Carcinoma
of Low Pelvic
as recorded from measurement of the pathologic specimens for each group was 5 cm. The Duke classification of tumors was also similar in the two groups. Regardless of whether anterior or abdominoperineal resection was elected, the inferior mesenteric artery was first ligated adjacent to the aorta. Mobilization of the entire descending and part of the transverse colon was also required to permit either anastomosis or colostomy sufficiently proximal to the lesion, to provide adequate blood supply, and to include lymphatic drainage from the entire superior drainage area. Wide pelvic dissection to a level at least 3 cm. below the tumor was also performed in both anterior and abdominoperineal resections. Anterior resection, thus, herein implied resection of the descending colon with anastomosis between the serosa-covered proximal colon and the rectal stump well below the peritoneal reflection. Thus in both procedures an extensive mesenteric resection was accomplished. Since technical difficulties predisposed to the major complication of suture line leakage, the side to end colorectal anastomosis advocated by Baker [7] was used in fifty-four of the eighty-nine anterior resections. In this procedure the proximal colonic segment is closed and a larger end to side anastomosis made immediately adjacent to the closed end of the proximal colon. This permits a wide anastomosis more easily accomplished deep in the pelvis using an open technic. RESULTS
Complication differences could be related primarily to the choice of procedure. Complications for the two procedures are compared in Table I. Fifty-three per cent of the patients had one or more complications after abdominoperineal resection ; only 40 per cent had complications after anterior resection. In 111 patients with lesions between 6 and 12 cm. from the anus, 50 per cent of those having abdominoperineal resection and 40 per cent of those having anterior resection experienced complications. Lesions between 12 and 15 cm. were associated with a 62 per cent complication rate after abdominoperineal resection and only 36 per cent after anterior resection. Regardless of the level of the tumor, urinary tract complications, including retention which often required prostatic resection for relief, were more comVol.lll,January
1966
Colon and Rectum
115
TABLEI POSTOPERATIVE COMPLICATIONS*
Locations
Abdominoperineal (per cent)
Wound Gastrourinary Gastrointestinal Pulmonary Other Total patients with complications
Anterior Resection (per cent)
16 24 14 4 10
13 13 14 6 10
53
40
* The higher incidence of complications after abdominoperineal resection is largely due to more frequent urinary tract problems, especially prostatic obstruction.
mon when the lower part of the rectum was resected. Thirty-five patients had fifty-two complications after anterior resection. Although the incidence of complications was slightly higher in those patients with side to end anastomosis, there were no leaks at the suture line or deaths in this larger group of fifty-four patients. Since there was no other significant difference in the results with high or low lesions or with end to end and side to end anastomoses, complications are better compared with those after combined abdominoperineal resection. There were eleven wound complications and two of these were dehiscences requiring surgical correction. Urinary retention was the most common urinary tract complication and occurred in nine patients. None of these required transurethral resection. Suture line leakage occurred in two patients. One of these was associated with pelvic abscess, peritonitis, and death. The other patient was treated by transverse colostomy and recovered. None of the fifty-four patients having side to end (Baker) anastomosis had suture line leakage. Other gastrointestinal complications included paralytic ileus in five patients and gastric distention in two. There were two cases of upper gastrointestinal hemorrhage, one subphrenic abscess, and one staphylococcal enteritis. Thirteen miscellaneous complications occurred in patients with anterior resection. Pulmonary complications were infrequent. These consisted of atelectasis (two), pneumonia (two) ~ and pulmonary embolus (one). There were three patients with thrombophlebitis, three
116
Williams et al.
Five year survivalin 118patientswith curative resections. Palliative resections performed between June 1950and June 1960are excluded. FIG. 2.
with unexplained fever, one with leukopenia, and one with a penicillin allergic reaction. Forty-nine patients had sixty-five complications after abdominoperineal resection. Wound complications comprised 23 per cent of the total and were usually insignificant. However, four wound dehiscences occurred in this group all of which required secondary closure using general anesthesia. Twenty-two patients experienced urinary retention and seven of these required subsequent transurethral resection of the prostate. Six patients with urinary retention had superimposed urinary tract infection. There were thirteen gastrointestinal complications representing 20 per cent of the total. One patient had obstruction of the colostomy stoma which required surgical correction. Miscellaneous complications accounted for 23 per cent of the total complications. Only four pulmonary complications arose after abdominoperineal resection. Two of these were atelecta-’ sis, one was pneumonia, and the fourth was pulmonary embolus. Other complications were electrolyte imbalance, unexplained fever, and leukopenia. The operative mortality was lower after anterior resection. Two patients died within thirty days of anterior resection compared with four deaths after abdominoperineal resection, a mortality of 2.2 and 4.3 per cent, respectively. Causes of death after anterior resection were aspiration pneumonia, peritonitis, and pneumonia after suture line leakage. No deaths occurred in the fifty-four patients who had side to end colorectal anastomosis. Pulmonary embolism, colostomy necrosis with peritonitis, cardiac arrest during surgery, and probable coronary occlusion caused death after abdominoperineal resection. In the patients having anterior resection,
there were no cases of frank fecal incontinence. Follow-up barium and sigmoidoscopy studies in the surviving eighty-seven patients show that there were no strictures at the suture line and, as far as could be determined, evacuation proceeded normally. Only one patient has had recurrence at the suture line. This recurrence manifested itself as red rectal bleeding and was biopsy proved by sigmoidoscopy. The patient was subsequently treated by abdominoperineal resection. Of the 118 patients having curative resection, the five year survivals were 57 per cent for anterior resection and 46 per cent for abdominoperineal resection. (Fig. 2.) Although the group is perhaps too small to be significant, 66 per cent of those patients with side to end anastomosis survived five years or more. Patients with Duke’s classification D and those treated after June 1960 were eliminated from this evaluation. If all cases are considered regardless of the extent of the disease surgery, the five year survival is 31 per cent in both groups. COMMENTS
Although results of this comparison of anterior and abdominoperineal resections for carcinoma 6 to 15 cm. above the anal verge do not settle the controversy, they are provocative. Similar results have been reported by Deddish and Stearns [lo] ; however, the mortality with anterior resection was higher than with abdominoperineal resection. It appears that if a similar dissection is performed, removing sufficient tissues lateral and at least 3 cm. inferior to the tumor, the choice of whether the remaining rectum is removed or not becomes technical. The low incidence of pelvic and suture line recurrence supports the contention that significant inferior spread of rectal cancer arising above 6 cm. is uncommon. The use of a side to end anastomosis low in the pelvis is easier and has decreased suture line leakage in this group. The mortality and complication differences in the two groups herein reported are less significant than the similarity of five year survivals. Urinary tract complications are one of several factors which encourage more frequent use of the rectum-saving procedure. The low incidence of suture line recurrence, equally low mortality, and comparable five year survival rates confirmed the impression of others [ll141 that the rectum need not be sacrificed for all lesions 6 to 15 cm. above the anus. The size American Journal of Surgery
Resections
for Carcinoma
of Low Pelvic
and location of the lesion will be less important than the size of the pelvis and other technical factors in the choice of anterior resection. The procedure of anterior resection for low lying carcinomas of the rectum has been criticized because lateral lymphatic pathways are not removed [8,9]. Recent reports suggest that lateral lymphatic spread occurs predominately when superior pathways are obstructed [6]. Tumor emboli have been found in the venous return [15] during tumor manipulation. These factors may be important; however, if the procedures of anterior and abdominoperineal resection are similar in their extent of dissection and manipulation, suture line recurrence assumes more significance. Its low incidence in this series remains unexplained since specific measures to prevent it have not been used. The effects of bowel preparation and irrigation were not evaluated. All patients had similar preoperative preparation consisting of a combination of sulfathalidine and neomycin, oral cathartics, and clear liquids, the latter on the day prior to surgery. The results with anterior resection should not be compared with those of so-called pullthrough mocedures. The mortalitv and five year &&als are comparable to those reported by many others with both abdominoperineal resection and resection with establishment of intestinal continuity [6,8,9,12-14,161. Many of these reports, however, show an incidence of anal incontinence ranging up to 40 per cent. Since no patient in our series had this complication, pelvic anastomosis seems preferable and can be accomplished with greater ease by utilizing the Baker technic [7].
1.
2. 3. 4. 5.
6. 7. 8.
9.
10.
A comparison is presented of anterior resection and abdominoperineal resection in 182 patients with carcinoma of the rectum 6 to 15 cm. from the anus. Anterior resection was per-
12.
Vol. Ill,
January 1966
117
REFERENCES
11.
cent, and a five year survival of 57 per cent. The technical ease of the side to end colorectal
and Rectum
anastomosis has been credited with a low incidence of suture line problems. These results suggest that the rectum need not be sacrificed in all lesions 6 to 15 cm. from the anus. Anterior and abdominoperineal resections are comparable if adequate lateral and inferior dissection can be accomplished when low anastomosis in the pelvis seems feasible.
SUMMARY
formed in eighty-nine patients and abdominoperineal resection in ninety-three. The extent of lateral pelvic dissection to 3 cm. or more below the lesion was the same for both procedures. Abdominoperineal resection was associated with 53 per cent complications, a 4.3 per cent operative mortality, and a five year surviva1 of 46 per cent. Anterior resection gave 40 per cent complications, a mortality of 2.2 per
Colon
13 14.
15.
MILES W. E. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2: 1812, 1908. COLLER,F. A., KAY, E. B., and MACINTYRE,R. S. Regional lymphatic metastases of carcinoma of the rectum. Surgery, 8: 294, 1940. GABRIEL,W. B., DUKES,C., and BUSSEY,H. J. R. Lymphatic spread in cancer of rectum. &it. J. Surg.,23: 395, 1935. GILCRIST,R. K. and DAVID, V. C. Lymphatic spread of carcinoma of rectum. Ann. Surg., 108: 621. 1938. GLOVER,R. P. and WAUGH,J. M. The retrograde lymphatic spread of carcinoma of the “rectosigmoid region”: its influence on surgical procedures. Surg. Gynec. & Obst., 82: 434, 1946. BERNHOFT, W. H. and PORTIN,B. A. Low rectal anastomosis: modified pull-through procedure. Arch. Sura.,90: 123, 1965. BAKER, J. -W. Low end-to-side rectosigmoidal anastomosis. Arch. Surg., 61: 143, 1950. DEDDISH,M. R. and WHITLEY,H. W. Complications of abdomino-perineal resection for cancer of the rectum. S. Clin. North America, 44: 449, 1964. GILBERTSEN, V. A. Adenocarcinoma of the rectum: a fifteen year study with evaluation of the results of curative therapy. Arch. Surg., 80: 135, 1960. DEDDISH,M. R. and STEARNS,M. W. Anterior resection for carcinomaof the rectum and rectosigmoidarea.Ann. Surp.. 154: 961, 1961. MAGO, C. W. Anterior &&ion for. carcinoma of the lower portion of sigmoid, rectosigmoid, and upper portion of the rectum: present status. S. Clin. North America, 37: 981, 1957. DUNPHY,J. E. and BRODERICK, E. G. A critique of anterior resection in the treatment of carcinoma of the rectum and pelvic colon. Surgery, 30: 106, 1951. POSTLEWAITE, R. W., ADAMSON, J. E., and HART,D. Carcinoma of the colon and rectum. Surg. Gynec. & Obst., 106: 257, 1958. WAUGH,W. M., MILLER, E. W., and KURZWEG, F. T. Abdomino-perineal resection with sphincter preservation for carcinoma of the mid rectum. Arch. Surg., 69: 469, 1954. FISHER,E. R. and TURNBULL, R. D., JR. The cytologic demonstration and significance of tumor cells in the mesenteric vein blood in patients with colorectal carcinoma. Surg. Gynec. & Obst., 100. 102, 1955.
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Williams et al.
16. BACON, H. E. Cancer of rectum
and colon: A critical analysis with recommendations to extend the rates of survival. Surgery, 41: 387, 1957.
DISCUSSION
\
J. ENGLEBERT DUNPHY (San Francisco, Calif.): This is a good study, and it reaffirms which should be observed by the appropriate precautions those of us who favor anterior resection. I think a 3 cm. margin estimated by the surgeon in the operating room is cutting it just a little fine. I wonder whether this is estimated after the specimen has been given to the pathologist. Some years ago we made a study of this and found that when the surgeon said he had 8 or 10 cm., the pathologist always called it 4 or 5 cm., and after it was placed in formalin it was 2 or 3 cm. So, we have tended to ask for a good 6 to 8 to 10 cm. below the lesion. The differences in survival simply reflect the differences in the biologic propensity of the lesions that are just a little below the peritoneal floor versus those at the peritoneal reflection. Others have shown that the prognosis for tumors below the reflection of the peritoneum, particularly if they are in the rectum, is less favorable than for those at or above the peritoneal floor. This best explains the more favored survival, and the obvious decrease in complications is the result of not having to mobilize the rectum and interfere with the innervation of the bladder. LUCIUS D. HILL (Seattle, Wash.): Dr. Baker wanted me to say a word about the present status of the side to end operation in our group. Since his original article some fifteen years ago, this technic has been employed in both benign and malignant conditions. In several cases of sigmoid diverticulitis in which there was fistula formation into the bladder, restoration of bowel continuity by this technic offered a more reinforced and convincingly secure anastomosis at a lower level than the usual end to end anastomosis offered. As to its application in the resection of cancer, the method permits a somewhat wider distal margin of resection than does the usual end to end anastomosis, but this should not be the determining factor in the choice between anterior and Miles’ resection. Rather, this should obviously be based on accepted pathologic concepts. The choice between an adequate resection on the one hand and unnecessary sacrifice of anal function on the other remains a difficult decision. A responsible answer requires a coordinated picture by the surgeon and the frozen section picture by the pathologist. With a small primary lesion, absence of satellite polyps, and absence of gross lymphatic spread, the surgeon may elect to preserve the anal sphincter even in a very low lying lesion. In these instances the side to end technic is useful; more recently we have also been employing the Swenson pull-through operation. Both of these may permit
the surgeon to satisfy the pathologic requirements of resection and still safely preserve anal function. Over the past fifteen years (and some of these patients have been actually followed up for some eighteen years), strictures have not developed, and we continue to maintain the side to end operation in our armamentarium. R. T. SHACKELFORD (Baltimore, Md.): The purpose of my discussion is to describe another operation that we have been using recently for carcinoma in the mid-rectum. It seems to us that the approach used by Dr. Russell Best, who combines an abdominal and perineal approach with sphincter preservation, has considerable merit. The operation by Dr. Best is performed through the abdomen. We do it in two teams. One surgeon and assistant operate through the abdomen and the other pair through perineum in an exaggerated lithotomy position. The abdominal surgeon does the abdominal part of the operation as has been described for a Miles’ procedure. The perineal surgeon removes the coccyx and inserts his finger around the rectum just above the anorectal ring. As long as that is preserved, sphincteric function is preserved. The entire distal portion of the alimentary tract is mobilized, and the perineal surgeon pulls out this portion, including the mesentery, for the desired distance transecting it at the appropriate levels. We previously used Dr. Best’s method of pulling the proximal colon down and anastomosing it end to end to the stump of the anus that remained. In the first twenty-seven patients nine perineal fistulas occurred; seven healed spontaneously but two required colostomy. To obviate that, we did experimental work on dogs and found that the proximal colon could be pulled through the stump of the anus, even though it was musoca-lined, and still function. Accordingly, in the last fourteen patients we have simply taken the proximal bowel and intussuscepted it through the anal canal and through the anus to the outside. Then it is pulled to the outside. With one suture we attach the anterior portion of it, and with another suture the posterior portion of it is attached to the anal skin. Those sutures slough out between the fifth and seventh day. We have not used any sutures at the proximal but at the end of the anal stump. There is no particular objection to using sutures here if you feel safer. After the skin sutures slough out the intussuscepted bowel retracts up into the anal canal. For the first two to six weeks the cervical stump feels just like a cervix projecting into the vagina, but as time goes on it softens and disappears. In a dog seen at the end of sixteen weeks, the anastomosis shows no ridge, there seems to be relatively little stenosis, and healing is quite firm. Recently we had our first opportunity to perform an autopsy on a patient who had had this operation American Journal of Surgery
Resections for Carcinoma of Low Pelvic Colon and Rectum as a palliative procedure for numerous liver metastases. Three and a half months postoperatively, the gross specimen and microscopic section showed the crypts of Morgagni and the mucosal lining of them at the point of anastomosis. Therefore, at the present time we think this operation does two things: by using a combined anterior and posterior approach the distance below the tumor can be seen and measured; a longer distance can be achieved between the anus and lower edge of the tumor and, therefore, a greater margin of safety as well as good function. BENTLEYP. COLCOCK(Boston, Mass.) : This paper touches upon one of the unsettled problems that we have to deal with almost every day, namely, what to do for carcinoma of the pelvic colon. There is not much difference of opinion if this lesion involves the rectosigmoid, by which I mean a lesion above the peritoneal reflection. I would, however, like to re-emphasize Dr. Dunphy’s viewpoint. I do not believe a 3 cm. margin below the lesion is enough. Unless it is measured at the operating table before it is divided, and there is a good 2 to 3 inch margin, the specimen will be 3 or 4 cm. when examined after the operation. The question remains about the true rectal ampulla, the lesion completely or partially below the peritoneal reflection. We have always thought that nothing but an abdominoperineal resection is adequate for this lesion. I would like to remind you of the experience at the University of Minnesota: in a Duke’s stage C lesion they found that only an abdominoperineal resection gave any significant five year cures for a lesion in this location. It takes but one involved lymph node to convert a Duke’s A and B to a Duke’s C lesion, and I know of no way to determine this at the operating table. It seems that one is forced to perform an abdominoperineal resection for most patients with carcinoma of the rectal ampulla. EDWARDS. JUDD (Rochester, Minn.) : The title of this paper would suggest that there might be competition between these two operations for lesions in the same general area. Dr. Yurko also mentioned a controversy. Most of us have settled this in our own way, and most, I hope, are selecting the operation much better than we used to. I think the whole point is to decide, after complete mobilization, whether we are really far enough away from the lesion. GORDON DONALDSON (Boston, Mass.) : About twenty years ago D’Allaines, of France, sent Dr. Allen a monograph on his procedure for carcinoma of the rectum. Our group has operated on about
Vol. 111, January
1966
119
twenty patients, and they have been carefully selected as to both the size and the site of the tumor. The results have been most gratifying in terms of both cure and anal function. This procedure is primarily an abdominoperineal resection, The coccyx is removed and a sigmoidoanal anastomosis performed. The anastomosis is protected by a complementary transverse colostomy, which is later closed. Small tumors between 6 and 12 cm. from the anal margin have been chosen for this operation. No operative deaths have occurred, and complications have not been serious. No permanent fistulas have resulted, and anal function has been much better than that provided by the pull-through procedure. Too few operations were performed for carcinoma prior to five years ago to validate longrange survival results. WILLIAM S. MCCUNE (Washington, D.C.): I would like to ask one question. I am old-fashioned enough to be in the habit of performing end to end anastomosis rather than side to end anastomosis. I would appreciate it, Dr. Yurko, if you would tell us why you can get a lower resection with the side to end than the end to end anastomosis. ROGER D. WILLIAMS(Columbus, Ohio) : I believe first I should answer jointly Dr. Dunphy and Dr. Colcock regarding the length of dissection below the tumor. We are speaking of 3 cm. as measured on the pathologic specimen. I would also like to emphasize that we are talking about the location of the lesion as being determined by sigmoidoscopy and the distance from the anal verge, and that during surgery the rectosigmoid area, particularly the rectum, can be so stretched that a tumor which initially appears quite low can be right up almost at skin level with considerable stretch in dissection. I appreciate Dr. Hill’s comments and would like to emphasize that the Baker anastomosis has been accomplished in many more cases than are shown in this series, since we limited this to the area 6 to 15 cm. from the anus. Dr. Yurko did not comment on suture line recurrence. We have had one in this series. There has been no suture line leakage with the Baker anastomosis, and there have been two with the end to end anastomosis. In reply to Dr. McCune’s question, I believe from a technical standpoint that when one is dealing with a much wider rectum the side to end anastomosis is easier, and our own experience would suggest from no suture line leakage that this has been technically better.
of Anterior
Abdominoperineal
Resections
Pelvic Colon and Rectal
and for Low
Carcinoma
ROGER D. WILLIAMS,M.D., ANTHONYA. YURKO, M.D., GRANT KERR, F.R.c.s., AND ROBERT M. ZOLLINGER,M.D., Columbus, Ohio
of patients at the University Hospital treated with anterior resection and abdominoperineal resection for carcinoma between 6 and 15 cm. from the anus suggests that anterior resection is the preferred procedure. This comparison includes location, size, and classification of the tumors, operative complications, mortality, fecal continence, and survival rates.
From the Defiartment of Surgery, The Ohio State University Hos@als, Columbus, Ohio.
Miles [1] proposed abdominoA LTHOUGH perineal resection as a more adequate operation for rectal cancer, more recent pathologic studies [Z-G] do not justify this radical procedure for all such carcinomas. The goal of surgery is to obtain the highest immediate and late survival with the fewest postoperative complications. Preservation of intestinal continuity would be ideal if the chance for cure were not jeopardized. In the area of the rectum below 6 cm. few surgeons would argue against total rectal and anal resection. The area between 6 and 15 cm., and especially between 6 and 12 cm., is controversial and has perhaps more advocates for abdominoperineal resection than for anterior resection with preservation of the sphincter. Comparison of nearly equal groups DUK?
NO. PATIENTS
rAEo-PER. IS ANT W6.14
MATERIAL Between January 1950 and December 1961, 182 of 830 carcinomas of the colon treated initially at the University Hospital were located between 6 and 15 cm. from the anus. The level of the tumor was determined by sigmoidoscopy. All lesions were also seen by barium enema, and a pathologic diagnosis was confirmed by biopsy. There were ninety-five men and eighty-seven women. Forty-nine women and thirty-nine men had anterior resection. The selection of the operative procedure was more often dependent upon the choice of the surgeon and the physical characteristics of the patient than tumor size, location, or local spread. Eighty-nine patients were treated by anterior resection, re-establishing colonic continuity, and ninety-three patients had abdominoperineal resection. In the latter group seventy-two (77.4 per cent) of the lesions were between 6 and 12 cm. while in 56.2 per cent of those in the former group the lesion was 12 to 15 cm. above the anus. Except for this difference in location, further analysis shows the groups nearly equal. As shown in Figure 1, the relative numbers of large lesions was comparable in the two groups and the median tumor size
CLf334FICZATl;N 32
34
II
32
27
I6
20
TUMOR SIZE (cm.) FIG. 1. Graphic representation of tumor size in 182 patients with carcinoma of the rectosigmoid. Based on tumor size and Duke’s classification the groups with anterior resection and abdominoperineal resection are comparable. 114
American Journal of Surgery
Resections
for Carcinoma
of Low Pelvic
as recorded from measurement of the pathologic specimens for each group was 5 cm. The Duke classification of tumors was also similar in the two groups. Regardless of whether anterior or abdominoperineal resection was elected, the inferior mesenteric artery was first ligated adjacent to the aorta. Mobilization of the entire descending and part of the transverse colon was also required to permit either anastomosis or colostomy sufficiently proximal to the lesion, to provide adequate blood supply, and to include lymphatic drainage from the entire superior drainage area. Wide pelvic dissection to a level at least 3 cm. below the tumor was also performed in both anterior and abdominoperineal resections. Anterior resection, thus, herein implied resection of the descending colon with anastomosis between the serosa-covered proximal colon and the rectal stump well below the peritoneal reflection. Thus in both procedures an extensive mesenteric resection was accomplished. Since technical difficulties predisposed to the major complication of suture line leakage, the side to end colorectal anastomosis advocated by Baker [7] was used in fifty-four of the eighty-nine anterior resections. In this procedure the proximal colonic segment is closed and a larger end to side anastomosis made immediately adjacent to the closed end of the proximal colon. This permits a wide anastomosis more easily accomplished deep in the pelvis using an open technic. RESULTS
Complication differences could be related primarily to the choice of procedure. Complications for the two procedures are compared in Table I. Fifty-three per cent of the patients had one or more complications after abdominoperineal resection ; only 40 per cent had complications after anterior resection. In 111 patients with lesions between 6 and 12 cm. from the anus, 50 per cent of those having abdominoperineal resection and 40 per cent of those having anterior resection experienced complications. Lesions between 12 and 15 cm. were associated with a 62 per cent complication rate after abdominoperineal resection and only 36 per cent after anterior resection. Regardless of the level of the tumor, urinary tract complications, including retention which often required prostatic resection for relief, were more comVol.lll,January
1966
Colon and Rectum
115
TABLEI POSTOPERATIVE COMPLICATIONS*
Locations
Abdominoperineal (per cent)
Wound Gastrourinary Gastrointestinal Pulmonary Other Total patients with complications
Anterior Resection (per cent)
16 24 14 4 10
13 13 14 6 10
53
40
* The higher incidence of complications after abdominoperineal resection is largely due to more frequent urinary tract problems, especially prostatic obstruction.
mon when the lower part of the rectum was resected. Thirty-five patients had fifty-two complications after anterior resection. Although the incidence of complications was slightly higher in those patients with side to end anastomosis, there were no leaks at the suture line or deaths in this larger group of fifty-four patients. Since there was no other significant difference in the results with high or low lesions or with end to end and side to end anastomoses, complications are better compared with those after combined abdominoperineal resection. There were eleven wound complications and two of these were dehiscences requiring surgical correction. Urinary retention was the most common urinary tract complication and occurred in nine patients. None of these required transurethral resection. Suture line leakage occurred in two patients. One of these was associated with pelvic abscess, peritonitis, and death. The other patient was treated by transverse colostomy and recovered. None of the fifty-four patients having side to end (Baker) anastomosis had suture line leakage. Other gastrointestinal complications included paralytic ileus in five patients and gastric distention in two. There were two cases of upper gastrointestinal hemorrhage, one subphrenic abscess, and one staphylococcal enteritis. Thirteen miscellaneous complications occurred in patients with anterior resection. Pulmonary complications were infrequent. These consisted of atelectasis (two), pneumonia (two) ~ and pulmonary embolus (one). There were three patients with thrombophlebitis, three
116
Williams et al.
Five year survivalin 118patientswith curative resections. Palliative resections performed between June 1950and June 1960are excluded. FIG. 2.
with unexplained fever, one with leukopenia, and one with a penicillin allergic reaction. Forty-nine patients had sixty-five complications after abdominoperineal resection. Wound complications comprised 23 per cent of the total and were usually insignificant. However, four wound dehiscences occurred in this group all of which required secondary closure using general anesthesia. Twenty-two patients experienced urinary retention and seven of these required subsequent transurethral resection of the prostate. Six patients with urinary retention had superimposed urinary tract infection. There were thirteen gastrointestinal complications representing 20 per cent of the total. One patient had obstruction of the colostomy stoma which required surgical correction. Miscellaneous complications accounted for 23 per cent of the total complications. Only four pulmonary complications arose after abdominoperineal resection. Two of these were atelecta-’ sis, one was pneumonia, and the fourth was pulmonary embolus. Other complications were electrolyte imbalance, unexplained fever, and leukopenia. The operative mortality was lower after anterior resection. Two patients died within thirty days of anterior resection compared with four deaths after abdominoperineal resection, a mortality of 2.2 and 4.3 per cent, respectively. Causes of death after anterior resection were aspiration pneumonia, peritonitis, and pneumonia after suture line leakage. No deaths occurred in the fifty-four patients who had side to end colorectal anastomosis. Pulmonary embolism, colostomy necrosis with peritonitis, cardiac arrest during surgery, and probable coronary occlusion caused death after abdominoperineal resection. In the patients having anterior resection,
there were no cases of frank fecal incontinence. Follow-up barium and sigmoidoscopy studies in the surviving eighty-seven patients show that there were no strictures at the suture line and, as far as could be determined, evacuation proceeded normally. Only one patient has had recurrence at the suture line. This recurrence manifested itself as red rectal bleeding and was biopsy proved by sigmoidoscopy. The patient was subsequently treated by abdominoperineal resection. Of the 118 patients having curative resection, the five year survivals were 57 per cent for anterior resection and 46 per cent for abdominoperineal resection. (Fig. 2.) Although the group is perhaps too small to be significant, 66 per cent of those patients with side to end anastomosis survived five years or more. Patients with Duke’s classification D and those treated after June 1960 were eliminated from this evaluation. If all cases are considered regardless of the extent of the disease surgery, the five year survival is 31 per cent in both groups. COMMENTS
Although results of this comparison of anterior and abdominoperineal resections for carcinoma 6 to 15 cm. above the anal verge do not settle the controversy, they are provocative. Similar results have been reported by Deddish and Stearns [lo] ; however, the mortality with anterior resection was higher than with abdominoperineal resection. It appears that if a similar dissection is performed, removing sufficient tissues lateral and at least 3 cm. inferior to the tumor, the choice of whether the remaining rectum is removed or not becomes technical. The low incidence of pelvic and suture line recurrence supports the contention that significant inferior spread of rectal cancer arising above 6 cm. is uncommon. The use of a side to end anastomosis low in the pelvis is easier and has decreased suture line leakage in this group. The mortality and complication differences in the two groups herein reported are less significant than the similarity of five year survivals. Urinary tract complications are one of several factors which encourage more frequent use of the rectum-saving procedure. The low incidence of suture line recurrence, equally low mortality, and comparable five year survival rates confirmed the impression of others [ll141 that the rectum need not be sacrificed for all lesions 6 to 15 cm. above the anus. The size American Journal of Surgery
Resections
for Carcinoma
of Low Pelvic
and location of the lesion will be less important than the size of the pelvis and other technical factors in the choice of anterior resection. The procedure of anterior resection for low lying carcinomas of the rectum has been criticized because lateral lymphatic pathways are not removed [8,9]. Recent reports suggest that lateral lymphatic spread occurs predominately when superior pathways are obstructed [6]. Tumor emboli have been found in the venous return [15] during tumor manipulation. These factors may be important; however, if the procedures of anterior and abdominoperineal resection are similar in their extent of dissection and manipulation, suture line recurrence assumes more significance. Its low incidence in this series remains unexplained since specific measures to prevent it have not been used. The effects of bowel preparation and irrigation were not evaluated. All patients had similar preoperative preparation consisting of a combination of sulfathalidine and neomycin, oral cathartics, and clear liquids, the latter on the day prior to surgery. The results with anterior resection should not be compared with those of so-called pullthrough mocedures. The mortalitv and five year &&als are comparable to those reported by many others with both abdominoperineal resection and resection with establishment of intestinal continuity [6,8,9,12-14,161. Many of these reports, however, show an incidence of anal incontinence ranging up to 40 per cent. Since no patient in our series had this complication, pelvic anastomosis seems preferable and can be accomplished with greater ease by utilizing the Baker technic [7].
1.
2. 3. 4. 5.
6. 7. 8.
9.
10.
A comparison is presented of anterior resection and abdominoperineal resection in 182 patients with carcinoma of the rectum 6 to 15 cm. from the anus. Anterior resection was per-
12.
Vol. Ill,
January 1966
117
REFERENCES
11.
cent, and a five year survival of 57 per cent. The technical ease of the side to end colorectal
and Rectum
anastomosis has been credited with a low incidence of suture line problems. These results suggest that the rectum need not be sacrificed in all lesions 6 to 15 cm. from the anus. Anterior and abdominoperineal resections are comparable if adequate lateral and inferior dissection can be accomplished when low anastomosis in the pelvis seems feasible.
SUMMARY
formed in eighty-nine patients and abdominoperineal resection in ninety-three. The extent of lateral pelvic dissection to 3 cm. or more below the lesion was the same for both procedures. Abdominoperineal resection was associated with 53 per cent complications, a 4.3 per cent operative mortality, and a five year surviva1 of 46 per cent. Anterior resection gave 40 per cent complications, a mortality of 2.2 per
Colon
13 14.
15.
MILES W. E. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2: 1812, 1908. COLLER,F. A., KAY, E. B., and MACINTYRE,R. S. Regional lymphatic metastases of carcinoma of the rectum. Surgery, 8: 294, 1940. GABRIEL,W. B., DUKES,C., and BUSSEY,H. J. R. Lymphatic spread in cancer of rectum. &it. J. Surg.,23: 395, 1935. GILCRIST,R. K. and DAVID, V. C. Lymphatic spread of carcinoma of rectum. Ann. Surg., 108: 621. 1938. GLOVER,R. P. and WAUGH,J. M. The retrograde lymphatic spread of carcinoma of the “rectosigmoid region”: its influence on surgical procedures. Surg. Gynec. & Obst., 82: 434, 1946. BERNHOFT, W. H. and PORTIN,B. A. Low rectal anastomosis: modified pull-through procedure. Arch. Sura.,90: 123, 1965. BAKER, J. -W. Low end-to-side rectosigmoidal anastomosis. Arch. Surg., 61: 143, 1950. DEDDISH,M. R. and WHITLEY,H. W. Complications of abdomino-perineal resection for cancer of the rectum. S. Clin. North America, 44: 449, 1964. GILBERTSEN, V. A. Adenocarcinoma of the rectum: a fifteen year study with evaluation of the results of curative therapy. Arch. Surg., 80: 135, 1960. DEDDISH,M. R. and STEARNS,M. W. Anterior resection for carcinomaof the rectum and rectosigmoidarea.Ann. Surp.. 154: 961, 1961. MAGO, C. W. Anterior &&ion for. carcinoma of the lower portion of sigmoid, rectosigmoid, and upper portion of the rectum: present status. S. Clin. North America, 37: 981, 1957. DUNPHY,J. E. and BRODERICK, E. G. A critique of anterior resection in the treatment of carcinoma of the rectum and pelvic colon. Surgery, 30: 106, 1951. POSTLEWAITE, R. W., ADAMSON, J. E., and HART,D. Carcinoma of the colon and rectum. Surg. Gynec. & Obst., 106: 257, 1958. WAUGH,W. M., MILLER, E. W., and KURZWEG, F. T. Abdomino-perineal resection with sphincter preservation for carcinoma of the mid rectum. Arch. Surg., 69: 469, 1954. FISHER,E. R. and TURNBULL, R. D., JR. The cytologic demonstration and significance of tumor cells in the mesenteric vein blood in patients with colorectal carcinoma. Surg. Gynec. & Obst., 100. 102, 1955.
118
Williams et al.
16. BACON, H. E. Cancer of rectum
and colon: A critical analysis with recommendations to extend the rates of survival. Surgery, 41: 387, 1957.
DISCUSSION
\
J. ENGLEBERT DUNPHY (San Francisco, Calif.): This is a good study, and it reaffirms which should be observed by the appropriate precautions those of us who favor anterior resection. I think a 3 cm. margin estimated by the surgeon in the operating room is cutting it just a little fine. I wonder whether this is estimated after the specimen has been given to the pathologist. Some years ago we made a study of this and found that when the surgeon said he had 8 or 10 cm., the pathologist always called it 4 or 5 cm., and after it was placed in formalin it was 2 or 3 cm. So, we have tended to ask for a good 6 to 8 to 10 cm. below the lesion. The differences in survival simply reflect the differences in the biologic propensity of the lesions that are just a little below the peritoneal floor versus those at the peritoneal reflection. Others have shown that the prognosis for tumors below the reflection of the peritoneum, particularly if they are in the rectum, is less favorable than for those at or above the peritoneal floor. This best explains the more favored survival, and the obvious decrease in complications is the result of not having to mobilize the rectum and interfere with the innervation of the bladder. LUCIUS D. HILL (Seattle, Wash.): Dr. Baker wanted me to say a word about the present status of the side to end operation in our group. Since his original article some fifteen years ago, this technic has been employed in both benign and malignant conditions. In several cases of sigmoid diverticulitis in which there was fistula formation into the bladder, restoration of bowel continuity by this technic offered a more reinforced and convincingly secure anastomosis at a lower level than the usual end to end anastomosis offered. As to its application in the resection of cancer, the method permits a somewhat wider distal margin of resection than does the usual end to end anastomosis, but this should not be the determining factor in the choice between anterior and Miles’ resection. Rather, this should obviously be based on accepted pathologic concepts. The choice between an adequate resection on the one hand and unnecessary sacrifice of anal function on the other remains a difficult decision. A responsible answer requires a coordinated picture by the surgeon and the frozen section picture by the pathologist. With a small primary lesion, absence of satellite polyps, and absence of gross lymphatic spread, the surgeon may elect to preserve the anal sphincter even in a very low lying lesion. In these instances the side to end technic is useful; more recently we have also been employing the Swenson pull-through operation. Both of these may permit
the surgeon to satisfy the pathologic requirements of resection and still safely preserve anal function. Over the past fifteen years (and some of these patients have been actually followed up for some eighteen years), strictures have not developed, and we continue to maintain the side to end operation in our armamentarium. R. T. SHACKELFORD (Baltimore, Md.): The purpose of my discussion is to describe another operation that we have been using recently for carcinoma in the mid-rectum. It seems to us that the approach used by Dr. Russell Best, who combines an abdominal and perineal approach with sphincter preservation, has considerable merit. The operation by Dr. Best is performed through the abdomen. We do it in two teams. One surgeon and assistant operate through the abdomen and the other pair through perineum in an exaggerated lithotomy position. The abdominal surgeon does the abdominal part of the operation as has been described for a Miles’ procedure. The perineal surgeon removes the coccyx and inserts his finger around the rectum just above the anorectal ring. As long as that is preserved, sphincteric function is preserved. The entire distal portion of the alimentary tract is mobilized, and the perineal surgeon pulls out this portion, including the mesentery, for the desired distance transecting it at the appropriate levels. We previously used Dr. Best’s method of pulling the proximal colon down and anastomosing it end to end to the stump of the anus that remained. In the first twenty-seven patients nine perineal fistulas occurred; seven healed spontaneously but two required colostomy. To obviate that, we did experimental work on dogs and found that the proximal colon could be pulled through the stump of the anus, even though it was musoca-lined, and still function. Accordingly, in the last fourteen patients we have simply taken the proximal bowel and intussuscepted it through the anal canal and through the anus to the outside. Then it is pulled to the outside. With one suture we attach the anterior portion of it, and with another suture the posterior portion of it is attached to the anal skin. Those sutures slough out between the fifth and seventh day. We have not used any sutures at the proximal but at the end of the anal stump. There is no particular objection to using sutures here if you feel safer. After the skin sutures slough out the intussuscepted bowel retracts up into the anal canal. For the first two to six weeks the cervical stump feels just like a cervix projecting into the vagina, but as time goes on it softens and disappears. In a dog seen at the end of sixteen weeks, the anastomosis shows no ridge, there seems to be relatively little stenosis, and healing is quite firm. Recently we had our first opportunity to perform an autopsy on a patient who had had this operation American Journal of Surgery
Resections for Carcinoma of Low Pelvic Colon and Rectum as a palliative procedure for numerous liver metastases. Three and a half months postoperatively, the gross specimen and microscopic section showed the crypts of Morgagni and the mucosal lining of them at the point of anastomosis. Therefore, at the present time we think this operation does two things: by using a combined anterior and posterior approach the distance below the tumor can be seen and measured; a longer distance can be achieved between the anus and lower edge of the tumor and, therefore, a greater margin of safety as well as good function. BENTLEYP. COLCOCK(Boston, Mass.) : This paper touches upon one of the unsettled problems that we have to deal with almost every day, namely, what to do for carcinoma of the pelvic colon. There is not much difference of opinion if this lesion involves the rectosigmoid, by which I mean a lesion above the peritoneal reflection. I would, however, like to re-emphasize Dr. Dunphy’s viewpoint. I do not believe a 3 cm. margin below the lesion is enough. Unless it is measured at the operating table before it is divided, and there is a good 2 to 3 inch margin, the specimen will be 3 or 4 cm. when examined after the operation. The question remains about the true rectal ampulla, the lesion completely or partially below the peritoneal reflection. We have always thought that nothing but an abdominoperineal resection is adequate for this lesion. I would like to remind you of the experience at the University of Minnesota: in a Duke’s stage C lesion they found that only an abdominoperineal resection gave any significant five year cures for a lesion in this location. It takes but one involved lymph node to convert a Duke’s A and B to a Duke’s C lesion, and I know of no way to determine this at the operating table. It seems that one is forced to perform an abdominoperineal resection for most patients with carcinoma of the rectal ampulla. EDWARDS. JUDD (Rochester, Minn.) : The title of this paper would suggest that there might be competition between these two operations for lesions in the same general area. Dr. Yurko also mentioned a controversy. Most of us have settled this in our own way, and most, I hope, are selecting the operation much better than we used to. I think the whole point is to decide, after complete mobilization, whether we are really far enough away from the lesion. GORDON DONALDSON (Boston, Mass.) : About twenty years ago D’Allaines, of France, sent Dr. Allen a monograph on his procedure for carcinoma of the rectum. Our group has operated on about
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twenty patients, and they have been carefully selected as to both the size and the site of the tumor. The results have been most gratifying in terms of both cure and anal function. This procedure is primarily an abdominoperineal resection, The coccyx is removed and a sigmoidoanal anastomosis performed. The anastomosis is protected by a complementary transverse colostomy, which is later closed. Small tumors between 6 and 12 cm. from the anal margin have been chosen for this operation. No operative deaths have occurred, and complications have not been serious. No permanent fistulas have resulted, and anal function has been much better than that provided by the pull-through procedure. Too few operations were performed for carcinoma prior to five years ago to validate longrange survival results. WILLIAM S. MCCUNE (Washington, D.C.): I would like to ask one question. I am old-fashioned enough to be in the habit of performing end to end anastomosis rather than side to end anastomosis. I would appreciate it, Dr. Yurko, if you would tell us why you can get a lower resection with the side to end than the end to end anastomosis. ROGER D. WILLIAMS(Columbus, Ohio) : I believe first I should answer jointly Dr. Dunphy and Dr. Colcock regarding the length of dissection below the tumor. We are speaking of 3 cm. as measured on the pathologic specimen. I would also like to emphasize that we are talking about the location of the lesion as being determined by sigmoidoscopy and the distance from the anal verge, and that during surgery the rectosigmoid area, particularly the rectum, can be so stretched that a tumor which initially appears quite low can be right up almost at skin level with considerable stretch in dissection. I appreciate Dr. Hill’s comments and would like to emphasize that the Baker anastomosis has been accomplished in many more cases than are shown in this series, since we limited this to the area 6 to 15 cm. from the anus. Dr. Yurko did not comment on suture line recurrence. We have had one in this series. There has been no suture line leakage with the Baker anastomosis, and there have been two with the end to end anastomosis. In reply to Dr. McCune’s question, I believe from a technical standpoint that when one is dealing with a much wider rectum the side to end anastomosis is easier, and our own experience would suggest from no suture line leakage that this has been technically better.