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Operations for cancer of rectum
OPERATIONS EXPERIENCES
FOR CANCER
AT THE UNIVERSITY
OF RECTUM
OF CALIFORNIA
HOSPITAL
MONTAGUE S. WOOLF, M.D. SAN FRANCISCO
A
CCORDING to Hayden,l who has summarized the history of procedures for cancer of the rectum and whose account I have used freeIy below, Lisfranc was the first to amputate the rectum and to report 9 cases from 18281830, but operated onIy for growths which were very low. For these he made an encircIing incision around the anus and dissected cIose to the rectal waI1 and then cut across the bowe1. In 1873, VerneuiI and Kocher removed the coccyx. Kocher aIso sutured the anus to prevent sepsis. Sir James Paget apparentry pIanned the first excision in EngIand in 1878. Harrison Cripps in the same country in 1884 pubIished 3 cases of perineal excision. One survived severa years. Kraske in 1883 removed part of the sacrum but the sphincter was preserved and the bowe1 abo\:e the resected portion puIIed into the sacral wound. For over twenty years such an operation was used aImost uni\-ersahy. Recurrence prior to 1884 was unIimited. By 1910, W. Ernest MiIes of London was definiteIy committed, owing to his idea of the wide spread of invasion in several directions which attends a growth in the rectum, to the idea of an abdominoperinea1 operation with a colostomy. In this operation, which he performs at the present time exactIy as he described it then, the bowel, the peIvic mesocoIon, the perirectal gIands and fat, the ischiorecta1 tissues and the sphincters were removed. This operation, done in one stage, Ieaving the patient with a permanent coIostomy, was in conception and even in practice of magnificent proportions. It is of a11 procedures the one most IikeIy to prevent recur-
rences, but it has been one, too, to which the patient most often succumbed. Such a procedure with, at first a grave mortaIity of 41 per cent even in MiIes’ hands, induced W. J. Mayo in 1912 to deveIop a technique which divided such an operation into two stages. He made an end coIostomy and inverted the end of the dista1 portion containing the growth unti1 a Iater date. His mortaIity was 13.3 per cent in 30 cases and as compared to 35 per cent when he used MiIes’ singIe stage method the former figure was a great improvement. The troubIe with this two stage operation was that the bIood suppIy of the dista1 Ioop was cut off so that it became gangrenous and septic absorption from this often kiIIed the patient before the second part was done. Therefore, Coffey devised his quarantine drainage of the infraperitonea1 space in which the dead segment of bower lay and reported a mortaIity of onIy 3 per cent. No one else has been able to approach so Iow a figure for such an abdominoperinea1 excision and it seems unIikeIy it wiI1 be repeated, unless candidates for it are carefuIIy selected. Other abdominoperineal operations have been devised; in 1915, D. Jones of Boston mobiIized the sigmoid, preserved an adequate bIood suppIy to the sigmoid and rectum, reconstructed the pelvic peritoneum to a higher Ievel, depressing the sigmoid beIow it. Then he constructed a Ioop coIostomy higher up, Iater removing the rectum and sigmoid from the perineum. This meant that in his second stage he was abIe to excise a good Iength of sigmoid with the rectum so that a growth could be removed higher up than in the Mummery type of procedure which it resembles. His average mortality is 22 per cent. 79
80
American
Journal
of Surgery
WooIf-Recta1
Lockhart-Mummery opens the abdomen, performs a Ioop coIostomy and removes the rectum from the perineum with as wide a dissection as possible. The coccyx is aIways excised. His mortaIity is 3 per cent in private cases and 14 per cent in charity cases. He obtained 54.8 per cent five year cures. Lahey divides the sigmoid, brings the upper end out in the iIiac region and implants the dista1 opening in the expIoratory wound. Later the dista1 opening is cIosed, the abdomen again entered and the dista1 Ioop depressed and removed at the same operation through the perineum. The Iower segment can be cIeaned this way in the interva1 but the abdomen is entered twice, adhesions have formed possibIy and the fIeId is IiabIe to be contaminated. It is useful in obstructed cases but one wouId think, if the obstruction is at a11 serious, a simpIer and more rapid decompression of the bowe1 might be more appropriate. More recentIy, Rankin and GabrieI have pubIished reports of a reverse type, a perineo-abdomina1 operation of similar characteristics. A Ioop coIostomy is performed. At a second procedure the rectum is dissected up as in the Mummery procedure but on opening the peritoneum the bowe1 with its growth is pushed into the abdomina1 cavity from which it is removed by an abdomina1 incision. This operation aIIows the remova of a tumor situated high up, if it cannot be done through the But not infrequentIy perineum aIone. the rectum may be opened accidentIy and the fieId contaminated. The abdomen has been entered also Iate in the operation and anesthetic diffIcuIties may be encountered especiaIIy if a theca1 anaIgesia with or without gas and oxygen has been used. Two major abdomina1 incisions have been made. In discussing the question of what course of treatment shouId be adopted for any surgica1 condition, it wiI1 be found that the most desirabIe operation is the one that can be used most extensiveIy under varying conditions; a minority procedure on the
Cancer
JANUARY. 1937
other hand, in time disappears but operations must be done finaIIy in a11 areas. There is aIso a phiIosophy in surgery which does not have much to do with uItimate statistics of rates of immediate and remote mortaIity but which has its importance in seIecting the operation. It must be remembered that the surgeon is IikeIy to have 2 patients after an operation which entaiIs a coIostomy, the one being the patient, the other the famiIy of the patient. There are tribuIations connected with the possession of a coIostomy which pervades the house of the one who has it. But it is equaIIy certain that a coIostomy has to be advised if the best hopes of the patient, which means Iife, are to be reaIized. The evoIution of the operations for cancer of the rectum easiIy demonstrate this. Again, these facts are cIear: a successfu1 coIostomy aIone wiI1 proIong Iife; a serious primary mortaIity is not compatibIe with the hopes of the reIatives of a patient who expend their means trusting to keep him aIive as Iong as possibIe, for the expense may we11 approximate the same figure whether the patient Iives or dies. Having these considerations in mind, we wiI1 return to certain figures regarding the operative mortality and rates of recurrence. TABLE TOTAL
NUMBER
OF CASES
Operabk cases. InoperabIe cases. Females.. Mates. .. AGE
I
OF CANCER
... .
46 40 26 60
OF THE RECTU~L-86 53.5 per cent
INCIDENCE
Years I~ZO............................. 2~30............................. 3~40............................. 40-50.............................. 50-60............................. 6o-70............................. 7~80............................. Operative MortaIity Analysed: ExpIoratory Iaporatomy and coIostomy........................... Resection. . TotaI operative mortality. . Excluding deaths from coIostomy
No. Cases I
3 II 13 28 24 6
6 deaths 8 deaths 16.2 per cent g. 3 per cent
The tota number of cases of cancer of the rectum at the University of CaIifornia since Igr 5 have been 86. Varying types of
operations have been done from the exact procedure of Kraske to that of MiIes. The operations were performed by many genera1 surgeons but by many fewer since 1926. Table I shows certain facts, nameIy, that 53.5 per cent were operable and that there were more than doubIe the number of males than femaIes. Operative mortaIity was 16.2 per cent, but if one ignores those dying from the coIostomy aIone, done very often for emergency and paIIiative reasons and carries a high death rate, then there were 8 deaths in 86 cases, or 9.3 per cent. TABLE FOSTOPERATI”E
II FOLLOW-UP
CRSCS who have had foIlow-up (z cases not foIIowed) foIlo\ving resection of growth rg cases still alive foIIowing resection; (rg cases dead since resection)
38
DURATION
OF LIFE
cent, were recipients of proIonged life aIthough in some the Iength of uItimate surviva1 is not yet known. Nineteen foIIowed since resection died but these aIso were benefited to the extent of 8, or 42 per cent, having Iived over two years. If a five year surviva1 is a basis of estimating the vaIue of resection, then it wiI1 be seen that of 46 resected cases, there were 21.7 per cent five year survivaIs. Since I 926 at the University of CaIifornia there has been an active proctoIogic department from which most of the resections of the rectum have been handIed, in nine years there having been 38 operabIe cases. In these there had been but one death, a mortaIity of 2.6 per cent, as Table III shows. TABLE
-
111
operabte cases who had resections I postoperative mortaIitv = 2.6 per cent 14 cases dead since resection 23 cases stiI1 alive since resection
38
Since Operation
After Operation
No. Cases
ANALYSIS
OF RESULTS
OF OPERATWE
_ lintler
Operations
6
1
3 2
I
2 3
Number ofCases
PROCEDCRES
Five
/ Operativcl Year / \lortaIitv/ I Surviv:lls I
I
4
Lahey Coffey (2 stage). Rankin (2 stage) Miles. Lockhart-hlummery-. LocaI excision.
2
:,
0
7
2
8
L
9 10
I
5
~
: z.2
I
11 I2
‘3 ‘4 Total.
. .i
2 rg deaths since resection
r g survivaIs
Number of 5 year cures stiI1 alive. Number of 5 year cures dead.. TotaI 5 year survivals.. Percentage 5 year survivaIs in resected operaI& (46) cases. . .
5 5 IO
21.7per cent
TabIe II shows the fate of 38 foIIowed cases after resection; 19 were stiI1 aIive and since, according to authorities1 coIostomy aIone does not proIong Iife two years, we may consider that of these 19 cases IO, or 53 per 1hlinistry of HeaIth, Rectum, London, 1927.
Report
on
Cancer
of the
About two-thirds of these have had the perinea1 resection of Mummery, 18.4 per cent having survived more than five years. In addition, TabIe III shows that of those dead of recurrence 3 survived over fiv-e years; in other words, so far there has been a 26 per cent five year surviva1 from the Mummery operation. These figures show nothing more than that in a modest way we, too, have improved markedIy the primary mortaIity and to a Iess extent Iowered the recurrence rate after operations for cancer of the rectum. with the Mummery Our experience operation has been eminently successful as
82
American
Journd
of Surgery
WooIf-Recta1
far as the primary mortahty is concerned; one death in 38 resections. By removing the Iower portion of the sacrum in addition to the coccyx, we have aIways been abIe to remove a growth in the rectum or at the rectosigmoid junction. No seIection of cases has been made; our figures incIude even growths that have perforated the outer coat of the rectum and in one case invaded the prostate. However, if a patient is of an age and build to indicate that a major abdomina1 operation wouId not entai1 grievous risks, we perform an abdominoperinea1 operation, preferabIy in one stage. EarIier I mentioned many operations devised to circumvent a high primary mortaIity and a Iarge recurrence rate. They a11 have been very heIpfu1 and each has been successfu1 in the hands of their originators, but I beIieve one has to confine oneseIf to advising the simpIest of procedures for genera1 widespread use. It is impossibIe for the outIying surgeon to seIect definiteIy a major procedure from many variations by the method of tria1 and error. Therefore, it is my suggestion that the perinea1 operation of Mummery and the one stage abdominoperinea1 operation of MiIes be adopted as the two important procedures for use in removing the cancerous rectum, The second part of the Iatter can not have a great effect on operative recovery. The procedure of a few. minutes
Cancer removes the mobiIized bowe1. A patient does not die from this but from the effects of the much greater intra-abdominal manipuIation. SUMMARY
The first amputation of the rectum was performed by Lisfranc in 1828. Up to 1884, even with improved operations recurrence was universa1. At the present time if patients are subjected to a suitabIe operation for a remova of a growth the primary mortaIity need not be more than about 3 per cent to IO per cent, according to the type of operation. The two operations being used with increasing success at the University of CaIifornia HospitaI are that of posterior resection preceded by a coIostomy and the abdominoperinea1 operation in one stage. Experience pIays a great part both in judgment and technique. This is shown by the reduction of mortaIity after 1926 when the operations were performed mainIy by a singIe person. This figure has faIIen from 16.2 per cent to 2.6 per cent. The rate of recurrence has not been reduced nearIy as much, the respective five year surviva1 figures being 21.7 per cent and 26 per cent, but we are not performing as Net the maximum one stage abdominoperinea1 numbkr of operations.
FOR CANCER
AT THE UNIVERSITY
OF RECTUM
OF CALIFORNIA
HOSPITAL
MONTAGUE S. WOOLF, M.D. SAN FRANCISCO
A
CCORDING to Hayden,l who has summarized the history of procedures for cancer of the rectum and whose account I have used freeIy below, Lisfranc was the first to amputate the rectum and to report 9 cases from 18281830, but operated onIy for growths which were very low. For these he made an encircIing incision around the anus and dissected cIose to the rectal waI1 and then cut across the bowe1. In 1873, VerneuiI and Kocher removed the coccyx. Kocher aIso sutured the anus to prevent sepsis. Sir James Paget apparentry pIanned the first excision in EngIand in 1878. Harrison Cripps in the same country in 1884 pubIished 3 cases of perineal excision. One survived severa years. Kraske in 1883 removed part of the sacrum but the sphincter was preserved and the bowe1 abo\:e the resected portion puIIed into the sacral wound. For over twenty years such an operation was used aImost uni\-ersahy. Recurrence prior to 1884 was unIimited. By 1910, W. Ernest MiIes of London was definiteIy committed, owing to his idea of the wide spread of invasion in several directions which attends a growth in the rectum, to the idea of an abdominoperinea1 operation with a colostomy. In this operation, which he performs at the present time exactIy as he described it then, the bowel, the peIvic mesocoIon, the perirectal gIands and fat, the ischiorecta1 tissues and the sphincters were removed. This operation, done in one stage, Ieaving the patient with a permanent coIostomy, was in conception and even in practice of magnificent proportions. It is of a11 procedures the one most IikeIy to prevent recur-
rences, but it has been one, too, to which the patient most often succumbed. Such a procedure with, at first a grave mortaIity of 41 per cent even in MiIes’ hands, induced W. J. Mayo in 1912 to deveIop a technique which divided such an operation into two stages. He made an end coIostomy and inverted the end of the dista1 portion containing the growth unti1 a Iater date. His mortaIity was 13.3 per cent in 30 cases and as compared to 35 per cent when he used MiIes’ singIe stage method the former figure was a great improvement. The troubIe with this two stage operation was that the bIood suppIy of the dista1 Ioop was cut off so that it became gangrenous and septic absorption from this often kiIIed the patient before the second part was done. Therefore, Coffey devised his quarantine drainage of the infraperitonea1 space in which the dead segment of bower lay and reported a mortaIity of onIy 3 per cent. No one else has been able to approach so Iow a figure for such an abdominoperinea1 excision and it seems unIikeIy it wiI1 be repeated, unless candidates for it are carefuIIy selected. Other abdominoperineal operations have been devised; in 1915, D. Jones of Boston mobiIized the sigmoid, preserved an adequate bIood suppIy to the sigmoid and rectum, reconstructed the pelvic peritoneum to a higher Ievel, depressing the sigmoid beIow it. Then he constructed a Ioop coIostomy higher up, Iater removing the rectum and sigmoid from the perineum. This meant that in his second stage he was abIe to excise a good Iength of sigmoid with the rectum so that a growth could be removed higher up than in the Mummery type of procedure which it resembles. His average mortality is 22 per cent. 79
80
American
Journal
of Surgery
WooIf-Recta1
Lockhart-Mummery opens the abdomen, performs a Ioop coIostomy and removes the rectum from the perineum with as wide a dissection as possible. The coccyx is aIways excised. His mortaIity is 3 per cent in private cases and 14 per cent in charity cases. He obtained 54.8 per cent five year cures. Lahey divides the sigmoid, brings the upper end out in the iIiac region and implants the dista1 opening in the expIoratory wound. Later the dista1 opening is cIosed, the abdomen again entered and the dista1 Ioop depressed and removed at the same operation through the perineum. The Iower segment can be cIeaned this way in the interva1 but the abdomen is entered twice, adhesions have formed possibIy and the fIeId is IiabIe to be contaminated. It is useful in obstructed cases but one wouId think, if the obstruction is at a11 serious, a simpIer and more rapid decompression of the bowe1 might be more appropriate. More recentIy, Rankin and GabrieI have pubIished reports of a reverse type, a perineo-abdomina1 operation of similar characteristics. A Ioop coIostomy is performed. At a second procedure the rectum is dissected up as in the Mummery procedure but on opening the peritoneum the bowe1 with its growth is pushed into the abdomina1 cavity from which it is removed by an abdomina1 incision. This operation aIIows the remova of a tumor situated high up, if it cannot be done through the But not infrequentIy perineum aIone. the rectum may be opened accidentIy and the fieId contaminated. The abdomen has been entered also Iate in the operation and anesthetic diffIcuIties may be encountered especiaIIy if a theca1 anaIgesia with or without gas and oxygen has been used. Two major abdomina1 incisions have been made. In discussing the question of what course of treatment shouId be adopted for any surgica1 condition, it wiI1 be found that the most desirabIe operation is the one that can be used most extensiveIy under varying conditions; a minority procedure on the
Cancer
JANUARY. 1937
other hand, in time disappears but operations must be done finaIIy in a11 areas. There is aIso a phiIosophy in surgery which does not have much to do with uItimate statistics of rates of immediate and remote mortaIity but which has its importance in seIecting the operation. It must be remembered that the surgeon is IikeIy to have 2 patients after an operation which entaiIs a coIostomy, the one being the patient, the other the famiIy of the patient. There are tribuIations connected with the possession of a coIostomy which pervades the house of the one who has it. But it is equaIIy certain that a coIostomy has to be advised if the best hopes of the patient, which means Iife, are to be reaIized. The evoIution of the operations for cancer of the rectum easiIy demonstrate this. Again, these facts are cIear: a successfu1 coIostomy aIone wiI1 proIong Iife; a serious primary mortaIity is not compatibIe with the hopes of the reIatives of a patient who expend their means trusting to keep him aIive as Iong as possibIe, for the expense may we11 approximate the same figure whether the patient Iives or dies. Having these considerations in mind, we wiI1 return to certain figures regarding the operative mortality and rates of recurrence. TABLE TOTAL
NUMBER
OF CASES
Operabk cases. InoperabIe cases. Females.. Mates. .. AGE
I
OF CANCER
... .
46 40 26 60
OF THE RECTU~L-86 53.5 per cent
INCIDENCE
Years I~ZO............................. 2~30............................. 3~40............................. 40-50.............................. 50-60............................. 6o-70............................. 7~80............................. Operative MortaIity Analysed: ExpIoratory Iaporatomy and coIostomy........................... Resection. . TotaI operative mortality. . Excluding deaths from coIostomy
No. Cases I
3 II 13 28 24 6
6 deaths 8 deaths 16.2 per cent g. 3 per cent
The tota number of cases of cancer of the rectum at the University of CaIifornia since Igr 5 have been 86. Varying types of
operations have been done from the exact procedure of Kraske to that of MiIes. The operations were performed by many genera1 surgeons but by many fewer since 1926. Table I shows certain facts, nameIy, that 53.5 per cent were operable and that there were more than doubIe the number of males than femaIes. Operative mortaIity was 16.2 per cent, but if one ignores those dying from the coIostomy aIone, done very often for emergency and paIIiative reasons and carries a high death rate, then there were 8 deaths in 86 cases, or 9.3 per cent. TABLE FOSTOPERATI”E
II FOLLOW-UP
CRSCS who have had foIlow-up (z cases not foIIowed) foIlo\ving resection of growth rg cases still alive foIIowing resection; (rg cases dead since resection)
38
DURATION
OF LIFE
cent, were recipients of proIonged life aIthough in some the Iength of uItimate surviva1 is not yet known. Nineteen foIIowed since resection died but these aIso were benefited to the extent of 8, or 42 per cent, having Iived over two years. If a five year surviva1 is a basis of estimating the vaIue of resection, then it wiI1 be seen that of 46 resected cases, there were 21.7 per cent five year survivaIs. Since I 926 at the University of CaIifornia there has been an active proctoIogic department from which most of the resections of the rectum have been handIed, in nine years there having been 38 operabIe cases. In these there had been but one death, a mortaIity of 2.6 per cent, as Table III shows. TABLE
-
111
operabte cases who had resections I postoperative mortaIitv = 2.6 per cent 14 cases dead since resection 23 cases stiI1 alive since resection
38
Since Operation
After Operation
No. Cases
ANALYSIS
OF RESULTS
OF OPERATWE
_ lintler
Operations
6
1
3 2
I
2 3
Number ofCases
PROCEDCRES
Five
/ Operativcl Year / \lortaIitv/ I Surviv:lls I
I
4
Lahey Coffey (2 stage). Rankin (2 stage) Miles. Lockhart-hlummery-. LocaI excision.
2
:,
0
7
2
8
L
9 10
I
5
~
: z.2
I
11 I2
‘3 ‘4 Total.
. .i
2 rg deaths since resection
r g survivaIs
Number of 5 year cures stiI1 alive. Number of 5 year cures dead.. TotaI 5 year survivals.. Percentage 5 year survivaIs in resected operaI& (46) cases. . .
5 5 IO
21.7per cent
TabIe II shows the fate of 38 foIIowed cases after resection; 19 were stiI1 aIive and since, according to authorities1 coIostomy aIone does not proIong Iife two years, we may consider that of these 19 cases IO, or 53 per 1hlinistry of HeaIth, Rectum, London, 1927.
Report
on
Cancer
of the
About two-thirds of these have had the perinea1 resection of Mummery, 18.4 per cent having survived more than five years. In addition, TabIe III shows that of those dead of recurrence 3 survived over fiv-e years; in other words, so far there has been a 26 per cent five year surviva1 from the Mummery operation. These figures show nothing more than that in a modest way we, too, have improved markedIy the primary mortaIity and to a Iess extent Iowered the recurrence rate after operations for cancer of the rectum. with the Mummery Our experience operation has been eminently successful as
82
American
Journd
of Surgery
WooIf-Recta1
far as the primary mortahty is concerned; one death in 38 resections. By removing the Iower portion of the sacrum in addition to the coccyx, we have aIways been abIe to remove a growth in the rectum or at the rectosigmoid junction. No seIection of cases has been made; our figures incIude even growths that have perforated the outer coat of the rectum and in one case invaded the prostate. However, if a patient is of an age and build to indicate that a major abdomina1 operation wouId not entai1 grievous risks, we perform an abdominoperinea1 operation, preferabIy in one stage. EarIier I mentioned many operations devised to circumvent a high primary mortaIity and a Iarge recurrence rate. They a11 have been very heIpfu1 and each has been successfu1 in the hands of their originators, but I beIieve one has to confine oneseIf to advising the simpIest of procedures for genera1 widespread use. It is impossibIe for the outIying surgeon to seIect definiteIy a major procedure from many variations by the method of tria1 and error. Therefore, it is my suggestion that the perinea1 operation of Mummery and the one stage abdominoperinea1 operation of MiIes be adopted as the two important procedures for use in removing the cancerous rectum, The second part of the Iatter can not have a great effect on operative recovery. The procedure of a few. minutes
Cancer removes the mobiIized bowe1. A patient does not die from this but from the effects of the much greater intra-abdominal manipuIation. SUMMARY
The first amputation of the rectum was performed by Lisfranc in 1828. Up to 1884, even with improved operations recurrence was universa1. At the present time if patients are subjected to a suitabIe operation for a remova of a growth the primary mortaIity need not be more than about 3 per cent to IO per cent, according to the type of operation. The two operations being used with increasing success at the University of CaIifornia HospitaI are that of posterior resection preceded by a coIostomy and the abdominoperinea1 operation in one stage. Experience pIays a great part both in judgment and technique. This is shown by the reduction of mortaIity after 1926 when the operations were performed mainIy by a singIe person. This figure has faIIen from 16.2 per cent to 2.6 per cent. The rate of recurrence has not been reduced nearIy as much, the respective five year surviva1 figures being 21.7 per cent and 26 per cent, but we are not performing as Net the maximum one stage abdominoperinea1 numbkr of operations.