Primary resection of the colon and rectum with particular reference to cancer and ulcerative colitis

PRIMARY RESECTION OF THE COLON AND RECTUM WITH PARTICULAR REFERENCE TO CANCER AND ULCERATIVE COLITIS* OWEN H. WANGENSTEEN, M.D. AND ROBERT W. TOON,~ .~linneapolis,

T

HE surgeon’s primary concern with the problem of visceral malignancy up unti1 quite recently has been with operative mortality. Perusal of the literature confirms this suggestion. The improvement which has come about in surgery generally- within the last few years definitely suggests that the surgeon, now having Improved considerably his record with reference to operative mortality, has begun to focus his attention more earnest13 upon the problem of ultimate cure of cancer. The perineal operation for rectal cancer and posterior excision of the rectum preceded by colostomy are reserved largely for the occasional patient for whom the conventional, abdominoperineal operation does not seem well suited. In most clinics professing an interest in the problem of recta1 cancer the nbdominoperineal operation has become the procedure of choice. In this clinic during the past fi\re years, attempts ha\,e been made to ascertain whether an abdominal dissection directed at removal of the lesion and the lymph node drainage area, accompanied by reestablishment of intestinal continuity, is a satisfactory operation for rectal and rectosigmoidal cancers. That such an operation can be done with an operati1.e mortality not out of line with that of the abdominoperineal operation is apparent in our own experience; that the operation is followed by satisfactory continence in most patients, especially when the end-to-end suture method has been employed, also has been established; that

M.D.

121innesota

this more conservative operation cannot have as high an ultimate cure rate for recta1 cancer as the abdominoperineal operation is also apparent in that omission of the perineal portion of the operation, particularly salvage of the levators, constitutes a less radical operation for rectal cancer. From our own experience it is yet too early to give an opinion in the matter of how much Iess efficient the more conservative operation is than the standard abdominoperineal operation. That is the particular point still to be clarified. Already in 1944, after two years’ experience with the operation in which sphincteric function was preserved, it was apparent that the operation was unsuited for dealing with low lying lesions in juxtaposition to the levators,‘.’ as well as for large, bulky, fixed cancers presenting Iymph node involvement. Accumulated experience from a number of sources suggests definitely that no surgeon employing even the most radical operation can lay claim to any important achievement in dealing with rectal cancers exhibiting lymph node involvement which fall into Dukes’ Group C Classification.“~ EarIier detection and earlier operation for rectal cancer are without question the items which must be looked to, in order that a more hopeful prospect will come about in the field of recta1 cancer. CAKCEK In cancer a one-stage

OF

THE

COLON

of the colon it is possible to do excision with remo\ral of the

* From the Departnlcnt of Surgery. University of hlinnesota hlctlical Scho:)l, I\linneaprJis, \Iinnesot:~. This prcsc’nt:ttion is based upon rrx~trches supportcbtt by grnnts from the Xlalignant Disc:w ~ksearch Fund. t N:ction:tl (knccr Fellow.

3x-I

lymphatic drainage area, preserving intestmal continuity in al1 operable cases. The Bloch-PauI-Mikulicz operation is an incomplete operation for colic cancer, and should be discarded by all experienced v,isceral surgeons. No surgeon should be found advocating general adoption of the abdominoperineal operation for rectal canat the same time employing the cer, exteriorization operation for cancer of the colon. Such practice smacks of inconsistency and suggests that the surgeon’s mastery of the abdominoperineal operation has superseded his accomplishment in the one-stage end-to-end anastomosis for colic cancer. Our associate, Dr. David State,‘” has advocated an extension of the nbdominoperineal operation for those patients who exhibit Iymph node involvement in the upper end of the inferior mesenteric artery pedicle; in such patients, he excises the entire left colon, together with the mesena colostomy in the tery, establishing transverse colon. The latitude for this extension of removal of the lymphatic drainage area is even wider in anastomotic operations. When numerous and enlarged lymph nodes are found in juxtaposition to a cohc Iesion, it has been routine practice for some years in this clinic to remove a considerable larger segment of the colon, thus enlarging the opportunitv of getting wide of the lesion. EspecialI>in lesions of the left colon is such a practice desirabIe. Having observed instances of recurrence about the ureter and the aorta after incomplete excision of the lymphaticdrainage area in cancers of the descending colon, excision of that segment together with the splenic and sigmoid flexures, establishing continuity bv anastomosing the transverse to the terminal peIvic coIon has become quite routine practice in this clinic for such lesions. hloreover, in a few instances, because of the finding of enlarged lymph nodes in the mesentery of ev~en more proximal reaches of the colon, the greater portion of the colon has been excised, nnnstomosing the ileum to the terminal

peIvic colon. In some instances the lymph nodes ha1.e been reported by the pathologist as benign. Yet, this circumstance is less embarrassing to both patient and surgeon than is incomplete removal of the involved by. the cancer lymph nodes process. Surgeons must now and then ha\.e occasion to entertain some misgiv+ngs ov.er such negative reports of lymph node involvement. Obviously the difticultv of recognizing a few cancer cells in a lymph node must be great. The biologic test constituted by the elapse of time, to be certain, is a sure test to determine vfrhether the pathologist’s observation was correct but it is not a risk to be run with the interests of the patient in mincl. Excision of an increased length of colon does not change the character of the surgical problem particularly and if one were to adopt this the surgeon would unpolicy uniformly, doubtedly be rewarded sufficiently often by the finding of unsuspected polyps as well as an occasional additional undetectecl cancer to justifv this extension of effort. In malignancies of the right colon the sentinel node at the inferior border of the pancreas alongside the mesenteric v~essels is to be sought out and remov,ed. In cancers of the transv.erse colon, the splenic and hepatic flexures should be unhinged from their phrenocolic attachments, thus pcrmitting removal of a wider segment of the mesentery, insuring at the same time adequate mobiIity of bowel to efl‘ect an end-to-end anastomosis without tension. Among the patients included in this stud? are three patients in whom it was necessar) to anastomose the proximal third of the transverse colon to the rectum because of node involvement in extensive lymph the inferior mesenteric artery lymphatic pedicle. Inasmuch as sacrifice of a good portion of the sigmoid colon v,oids the possibility of restoration of continuity between rectum and descending colon, the only alternative is mobilization of the transv.erse colon for the anastomosis. If the marginal vessels are well de-veloped, the mid-colic artery may evren be divided near

386

Amcrvx~~

.1twrn:,1

01 sursur

Wangensteen,

Toon--.Kesection

its origin and when the hepatic flexure and ascending colon are freed up, there is ample Iength of gut for an anastomosis to the mid-rectum. To those surgeons who are committed to employment of the open anastomosis, the antibiotics such as the suIfonamides employed as intestinal antiseptics or streptomycin are a great boon. The experience of this clinic with primary resection, employing the closed anastomosis in the preintestinal antiseptic era (1941 to 1943) strongly. suggests that employment of antibiotics is not a sine qua non of a I2 In that two year successfu1 operation. interval sixty-one consecutive colic resections were done including the rectosigmoid area with one death, a hospita1 mortality of I .6 per cent which is an accomplishment we have been unable to duplicate since, even with preoperative administration of intestimd antibiotics to occasional patients. In every operative series of some size, when one is dealing with cancer, there enters alwavs the item of unav-oidable deaths; that”is, losses in the postoperative phase from coronnrv and cerebral artery thrombosis and similar causes. The time may come when even death from pulmonary embolism will be looked upon as an avoidable cause of death. In the 1941 to 1943 experience there were no unavoidable deaths; in the 1943 to 1945 period, during which seventy-eight colic resections were done, there were six hospital deaths, a mortality of 7.6 per cent; three of the deaths, however, were owing to unavoidable cause. In other words, in the first series we used up a Iot of surgical luck in having no unavoidabIe deaths. The score was evened up by the law of averages in the second series, giving us an overall hospital mortality of 5 per cent for both series.‘” THE

PRESENT

STUDY

It is the writers’ intent in this effort to indicate what the experience of this clinic has been with anastomotic operations for rectal and rectosigmoidal lesions. It is still

of Colon

I:I.mRVnRV. IC)lX

too early to assess fully the accomplishment of the Iow anastomosis in dealing with primary rectal mahgnancies. Yet, enough experience has been accumulated to suggest what the outlook may be for the dua1 objective of curing the cancer and, at the same time, salvaging sphincteric function. A serious interest in the problem of the of anastomosis with preservation low sphincteric function in this cIinic dates back to 1942. It is the experience of those which will be reviewed herein. years Essential data concerning the patients and the operations are to be found in the tables. We have divided somewhat arbitrarily the surgica1 problem into two categories: (I ) Those lesions situated within 13 cm. from the anus are regarded as being present in the true rectum; (2) those lesions beyond 13 cm. and not more than 20 cm. from the anus are considered as being in the rectosigmoid area. The term rectosigmoid is also a rather arbitrary and not strictly an anatomic designation. However, prior to the BNA recIassilication of the constituent parts of the pelvic colon and rectum, the coIon pelvinum, that segment of the colon between the distal end of the sigmoid flexure and the present arbitrar! upper limits of the rectum (the third sacral vertebra) was included in the rectum. Surgeons, generally, employ the appellation rectosigmoid to this segment of colon. In others words, in this study the operntions have been divided into a high and low group. No lesions situated beyond 20 cm. from the anus have been incIuded in this study. The majority of the patients had primary carcinomatous Iesions of either the rectum or the rectosigmoid. In addition, there is a miscellaneous group constituted by a variety of conditions including primary lesions of the rectum which on microscop~c study proved to be benign, extrinsic tumors invoIving the rectum and a few instances of diverticulitis. There is also a third group constituted by patients with uIcerative colitis for whom primary intestinal resection and annstomosis was done,

In this latter group, inasmuch as it was considered desirable to include all the patients having primary resection for ulcerative colitis, there are one or two inclucled in whom the lower level of the lesion \vns :t little higher than the arbitrary 20 cm la~cl from the anus. OI’EILATIVE

TECHKIC

EMPLOYED

The maiorit> of the patients ivere operated upon employing the end-to-end suture technic. In the main, it can be saicl that one can make a satisfactorj. snastomosis at n level lower than it is sn’fe to cure cancer. Because of the depth of the wound, ;I single ro\v of sutures must sufIice for the anastomosis. Interestingly enough, the results ha1.e been so satisibctory that \vc haye come to emplo)- a single row of interrupted silk sutures (oooo) as the standard manner in which to effect an anastomosis an> where in the gastrointestinal canal. M’e cmplo). the Lembert type of stitch, spacing the sutures approximateI?, 3 mm. apart. This somewhat close placement of the stitches makes for a rather large number of sutures, approximateI>: forty sutures in the ordinnr>. anastomosls. A large and p:ltulous stoma follows this scheme of anastomosis quite uniformly. The low anastomosis has been made bl, suture from kvithin the abdomen as low as 3.5 cm. from the anal orifice with primar) healing kvithout formation of a sinus or listula. The number of instances in which an :\nastomosis has been effectecl at as IOM ;I ICI-el as 5 cm. from the anus without temporary fistula formation, however, is f’e\y. !kloreover, inasmuch as our omn suggests quite definitely that csperience c\.en in the early lesion the \-cry IOM ;I nastomosis is contraindicated because of the likelihood of incomplete remo\-al, the nectwitj for performing anastomosis at levels below 5 cm. is not frequent. The abdomino-:LnaI pull-through operation has ;I limited indication. Inasmuch as healing is slo\v with this method, we have come to cmplo!. complemental co&tom>in all such instani.Ts. Complete fecal de\.intion can Ix

achieved b\, a single loop colostomy.” Then, when the segment of the pelvic colon pulled through the kus has healed secureI>., the colostom)can be closed. Healing in the direct suture anatomosis is orclinaril~ rapid, permitting dismissal of patients from the hospital usually within ,:I \veek ot performance of the operation. I rI patients in the upper group of rectal lesions ( 14 to 20 cm.) dismissal from the hospital five to six cln~s after operation is the rule, just as in colic resection in the more prosimal reaches of the colon barring complication. The operation without complication is the surgeon’s first objective. It is s\non\‘,mous Lvith low mortality as well as low morbidity. Details of the technic in the performance of these operations have been describecl elsewhere and Lvill not be repeated here.

From Table I, it is to be wted that during the J-ears 1945 and 1946 at thr UniversityHospitals -8 per cent of patients admitted to the surgical wards for treatment of cancer of the rectum or rectosigmoid underlvent some t\.pe of radical operati\.e procedure. In 56.4 per cent of‘ instances the nbdominoperinenl operation was done and in 43.6 per cent the mort conserx.nti\.e procedure of excision of thrs cancer Lvith sphincter preser\.ation \va.s done. Among the eighty-se\~en excisions of thrs rectum or rectosigmoid with sphincter preser\.ation reported herein, there \verc sixty-three (72.4 per cent) so-called curative operations; the remaining t\vent>;-four (27.6 per cent) were palliati\-e excisions ivith restoration of boxvrl continuit,y. In this study the follo\ving criteria have been employed to charncterizc the palliative mctnstases; I2 ) resection : ( I I hepatic lymph nodes or eviclentcs ot peri-aortic peritoneal metastases other than in the inferior mesenteric lymphatic pedicle; and (3) indurated lesions presenting high grade fixation to adjacent structures. 7 he I~:Iiorit!. of these p:lIliati\ v resections fell

into the first category, i.e., patients with demonstrable hepatic metastases. Table I suggests, in the main, that the pathologic grading or division of cases essentialI>employing Dukes’ classification is that essentially reported in larger series T.4131.i.

the division of patients was as follows: Dukes’ group A, twenty-three patients (36.5 per cent); group B, eleven patients (27 per cent) and in group C, twenty-three patients (36.5 per cent). In other words, the case alignment in the curntilre group of

I

Per ( 1c.nI 20 20

.$li 100

in which the abdominoperineal operation has been carried out. In a study of the St. Marks Hospital material, Gabriel; reported the folIowing di\-ision of their cases: Dukes’ group A, I 5 per cent; group B, 36 per cent and group C, 49 per cent. In this present series of anastomotic procedures, resection was undertaken as a palliative operation in twenty-four patients or 27.6 per cent of the eighty-seven patients in the group. Of the eighty-seven patients subjected to operation (Table I) 52 per cent fell into Dukes’ groups A and B and 48 per cent into Dukes’ group C. However, the division between the A and B cases was somewhat different in the present series, 26 per cent in each group, as contrasted with 15 per cent for Group A and 35 per cent for Group B as reported in the study by Gabriel in 1936. However, amongst the sixty-three curative operations undertaken in this series,

operations selection.

suggests

SUXMAHY

definiteI>,

OF

some

case

RESULTS

It is obviously too early to attempt to assess in a final manner the results of treatment of the more conservative operntion in the cure of cancer of the rectum and Our experience with the rectosigmoid. procedures is summarized in Tables II to XI incIusive. This analysis is recorded in some detail in the hope that a study of the tables may prove helpfur to others in assessing the worth of nnastomotic operations in dealing with cancer of the rectum. BriefI\ summarized, these data suggest: (I) Rest;tution of intestina1 continuity may be reestablished as a one-stage operative procedure after excision of the terminal peIvic colon and upper rectum with a hospital mortality that is in keeping with

Lc,,

I .\.\\.

NC,.

2

that attending dominoperineal I\‘. I

performance of operation. (Tables

the III

nband

(2) Functional sphincteric control is complete after the suture operation. (3) Accompanying the abdomino-anal pull-through procedure good sphincteric control is the rule although IOO per cent recover!’ of function is not consistentI> ~I‘AlSl 1. I\

c \KLIhC)\1 01 ,111.,,, I on I’kl.\ I( ~‘01.0~IlOSil~l’l~l.U”,cTAI.I~,\Ih PI
obtained; moreo\‘er, the healing phase i> longer and it is Lvise to make :I complemental di\.ersionary colostom! to a tforcl rest to the pelvic colon pulled through the remaining distal sphincteric segment. Ilaintenance of normal continence in the suture operations is owing to preser\.ution of the internal sphincter. E\.en in suture :lnastomosis made at _I or 3 cnl. from the ;IIILIS,continence in these patients has been invariably good. Any operation’ which eliminates the internal sphincter excludes the possibilit>, of sutisfac.tor>, continence. Even in the pull-through operation as done in this clinic, in which the rect;.il mucosa near the anorectnl line is removed, rlf’hiteto thtk injur;, maneuver ), some head

C.-\KCINOILl~

OF

‘THE

KECTIJhl

RESECTION

AND

(BOTH

LOU‘

PELVIC

GROUPS)

COLON

RESECTION

WITH

\\~ITH ABDO~IINO-ANAL 1942 to June,

January,

PKIM.AKY

ANASTOhlOSIS

AND

PULL-THROUGH

194:

x7 0

No. c:cx% l lospital mortality

No. follow-L~~,.

I?.\[,. (:;I.’

I .iving

I Per (:cnt

No.

3

T.ABLE .AKCINOhlh

OF

THE

KECTL’M

AND

LOW

LESIOWS

PELVIC

13 TO Janu:~r~,

VI

COLON 20 1942

KESECTIOIi

Ch1. to

WITH

(UPPER

PKI.MAK\-

FOR

Junc~, IC).+~

,.,...

Total casts. 1 lospit~tl mortality No fi~lIo\v-up

No.

Per

I

.,......

20

I o

,...

No.

hS.ASTOhlOSIS

GROLP)

Cent No.

\r,,

I \YV,

SC>

U:angensteen,

2

Toon-Kesection TABLE

ChRCINOMA

OF THE

KESECTION

RECTUM R‘ITH

AND

LOW

PELVIC

ABDOMINO-ANAL

of

VII

COLON

RESECTION

PULL-THROUGH 191.2 to June,

January,

(0

TO

1947

No. cases I luspitd

mortality

No follow-up

TABLE

( AI
RECTUM FOR

AND

LO\‘,’ PELVIC

LESIONS

(0

TO

January, 7‘ot:tl c:,s(‘s. I lospitd mort:rlit~No

follo\v-ul>

VIII

COLON ‘3 ~qp

KESECTION

C.\l.)* to June,

(LO\\.EK

.4ND HOCHENEGG

I’1 LL-1’HHOi

GKOl.1’)

,94-

IO I

0

Cl1

392

American

Journalof Sllrg~ryWangensteen,

Toon-Resection

patients approximately the same promise of cure as does the more radical abdominoperineal operation. For lesions in this area presenting dubious or borderline operability the abdominoperineal operation is the procedure of choice.

internal sphincter probabIy occurs, for the continence in this group of patients is by no means as complete as in the suture Moreover, as contrasted with the group. frequent loss of the sex function in males who have undergone abdominoperineal TABLE CARCINOMA

OF THE

RECTUM.AND

how LESIONS

PELVIC 0 TO

IX

COLON

I3

r:EenLl*nV, 1rL$i

of Colon

RESECTION

CM.

(LOWER

Januwy, 10.1.~ to June, Totalcases ..,.,,....,...._...._..........,....,...._..,,..._..._........._,,,....... I Iospital mortality. No foll ow-up............. ,.....,.............,,...,..

WITH

PRIMARY

ANASTOMOSIS

FOR

GROUP)

,947 51 3 0

. . .._....._._....._..

! Present St:itus of tht. <:ur:ctivc

Cases

I No.

i 1

2 I

00

0

25 .o

0

4 I I I

44.5 33-3 0 00 I). 00

IO

I,.

l20.()

; )

21

Per Cent

2 2 0 0

.o

4

’ Expired carcinolnn--rspired of thr primary carcinoma of the rectum, either recurrence 2 Expired other--expired of cnuses orher than the primary carcinoma of the rectum. 3 Local recurrence~local recurrence of the carcinoma in the :~rea of the original lesion.

excision of the rectum, preservation of that function is the rule in the low anastomosis. (4) In lesions of the rectosigmoid (upper segment I.J to 20 cm.) local recurrence has not followed the type of operation described herein. (Table VI.) (5) The incidence of local recurrence follo\ving conservative procedures for lesions at 8 cm. or less from the anus is frequent enough to suggest that sphincter saving operations are contraindicated in all low-lying lesions; with abandonment of the conservati\,e operations for lowlying lesions there will be less necessity for performance of the abdomino-anal pullthrough operation. (6) In the middle rectal segment or rectal ampulla above 8 cm. the conservative operation is a satisfactory operation for suitable cases and holds out to such

LOCAL

or nwt:\stnses.

RECURRENCE

The incidence of local recurrence in the curative groups is outlined in Table XI. Among these fifty-one patients operated upon, local recurrence has been observed in seven or 14 per cent of instances. Among these instances of local recurrence five or 70 per cent occurred in lesions at 8 cm. or less from the anus; two or 30 per cent occurred in the resections done for lesions between 9 and 13 cm. from the anus. One of these patients had a large colloid cancer which is notably difficult to cure;’ the other had a large Dukes’ group C lesion in which it became necessary to bring down the proximal third of the transverse colon for anastomosis with the mid-rectum because of large lymph nodes of the presence beyond the reaches of the conventional

\or

t .XY\‘.

NJ>

L

Wangensteen,

Toon-Resection

excision of the inferior mesenteric artery IyTmphatic pedicle. Among the twenty-four patients upon whom palliative resection lvas undertaken local recurrence was observed three times; twice in the groups in which the lesions were 6 to 8 cm. from the ‘I-ABLE

of Colon

.I,Wr,\.,lIll ilirp’ ry 393 A,,,(‘T,CilII

Gilchrist who have been keen exponents of the necessity of liberal excision of the I\-mphatic drainage area in operations for cancer of the rectum, find on a studv of their cases of abdominoperineal operation that the incidence of local recurrence S

( ‘I;1ns Per

c:t.nt

A (“: A :il A I3 (: A :: A H (:

,-

:

A R (1

IO

anus and once in the group in which that lesion was 9 to 13 cm. This latter patient exhibited al1 three of the features which were designated above to characterize the palliative operation in this study. Almost invariably, the local recurrence has not been primarilv at the site of the annstomosis, but outside of it, extending into the bowel secondarilv, a circumstance which suggests that it is the lateral invisible spread of cancer that the more conservative operation faiIs to dea1 with ltdequatelv. On this score, however, no operation’is free from blame. David and

I I

-14

amongst the fiv.e-year survivors was 22 per cent.R Inotherwords, theabdominoperineal operation, the most radical of available curative operations, is also an incompIete operation for certain cases. That it may be for any lesion that extends beyond the longitudinal muscles of the rectal wall is careful scrutiny of any apparent on anatomic atlas which depicts the compartments of the pelvic fascia. Local recurrence is an indictment of any operation and is synonymous with inadequate excision. It is to be noted (Table VI) in those instances in which the curativ,c

operation was undertaken for lesions at 11 to 20 cm. from the anus, there were no loca1 recurrences. This circumstance suggests rather definitely that for lesions in the rectosigmoid the conservati\;e operation is probably just as effective for the

cure of cancer as is the abdominoperineal operation.‘” The very- circumstance that recurrence is observed after the excision of a low-lying Dukes’ Group A lesion outside of the site of anastomosis suggests that this or any other classification subdivides cases occasionally beyond what is justified by subsequent developments. In other words, a demonstrated Dukes’ Group A lesion occasionally is shown by the elapse of time and growth of the lateral invisible spread to belong actually in Dukes’ Group C. A closer correlation between the presence of venous invasion by the tumor and the Dukes’ grouping is in order. That such venous invasion is rather frequent as well as ominous has been estnblished.‘J Careful stud?; to note the absence or presence of such venous invasion is important to assess thoroughly the possibilit>of cure in an] lesion. Unfortunately, such a study was not made routineIy in this group. It is certain that as one enlarges the indications for operation the number of patients with occult metastases will be larger.

UNSUSPECTED

POLYPS

SEGMENT

IN rZ MOKE

OF THE

I’KOXlMi\L

COLON

The frequency with which unsuspected polyps were encountered in this series is startling and suggests that if one \vere determined to 1eaL.e no stone unturned to lea\re such precursors of colic cancer behind, h e probably would be fully justified in excising the entire left colon, anastomosing the proximal third of the transverse colon to the rectum, a feasible operative procedure and one which was performed three times in this series of cases. As was stated pre\,iously for lesions in the descending colon, it has become regular practice in this clinic to excise the splenic and sigmoid ffexures, anastomosing the trans\.erse colon to the terminal pelvic colon. Certainly when one does the abdominoperineal operation for cancer in the lower and mid-rectal segments it is wise always to remove from above earl! in the operative procedure that segment of the sigmoid colon beyond the site chosen for colostomy down to the peritoneal reflection for purposes of inspection b-y the pnthologist. Every now and then, the finding of a polyp or even a small fiat independent cancer, undetected by sigmoidoscopic examination, may reward the surgeon for the observance of a caution which by some may be regarded as unnecessary. Such findIngs suggest the necessity for continuing the excision of segments proximally until no further lesions are encountered. And when one is contemplating anastomotic operations the proximal third of the transverse colon is a good stopping place, even when the anastomosis is to be made to the mid-rectum. In this connection an interesting report of Mayo and Schlicke” of an autopsy stud)of poIyps in the colon is of some importance. In patients coming to autopsy in whom the primary lesion was cancer of the colon or rectum, an additional polyp or pol?;ps were found in 34.1 per cent of all patients. hloreover, an independent unsuspectecl cancer was found in 4,. I&per cent

of inst:inces. In patients dying of disease other than primary cancer of the colon or rectum, the incidence of polyps w:~s 14 per cent. The incidence of polyps reported in the Mayo Schlicke study IS considerabl) higher- than is reported generally in barium and proctoscopic studies. In exminations i II Ii\ i ng patients, such unsuspected polyps are found ordinaril~~ in 2 to - per cent of instances. Inasmuch as the poI>.p is :I frccluent precursor of colic or rectal cancer, it is certain that addition:11 unsuspected polyps are more likely to be found in lxit‘ients \vho come for the treatment ot rectal or colic cancer. In and’ case it bchoo\.es the surgeon operating for mnlign:~nc~. of the colon or rectum to be\vare lest hc o\-erlool~ a precursor of :l malignancy OI- an alreacl!. existing independent cancer. It’ the AI:IJ.o and Schlicke obscr\.:ltions are borne out in similar future studies, the surgeon \vho undertook to extirpate regular-l!. the entire left colon, the area in which polyps are found most frequently, for Icsions in\.ol\-ing either the rectum, rectohigmoicl or sigmoid colon, could probabl\~ justif‘?, his rashness 1~~. the finding of unsuspected potential malignancies or alread! existing independent cancers in sufficient numbers to justify the extra labor. Swinton MIMI I-Iaug” report upon :I similar autops!. study of I ,843 patients. The>- observed an incidence of benign polo-ps in 7 per cent of these pnticnts. In 42 per cent of the patients I\-ith polyps two or mow benign Icsions \verc present. EhRLIER

RECOGNITIOS

W’hether cvc deal bvith the point of entr) or crit or intermediate conduits or reser\.oirs in bctm-een the portals of the ali\ve all know ho\v ver) mentar!’ tract, important is early diagnosis for the succcsful management of cancer. Much as we lament the failure of patients to heed the warning of blood in the stool, pain or slight change in the bowel habit with reference to cancer in the lower reaches of the alimentar~~ tract, ?.et an even more primary concern is that \,isceral cancer is :I silent

disease. The length of time in\.olved in the transformation of normal epithelinl cells from a normal mucous membrane into m:tlignnnt cells is not kno\vn; how long it takes before in\-nsive features cause the appearance of symptoms is undoubtedI> n variable period, perhaps usuall,~ in excess of a Iear. Inasmuch as cancer of the alimentarv canal including the colon and rectum is frequent and because cancer is an insidious and silent discase, \ve should take the pains to carr!- this instruction to the pubIic; moreover, \ve shoulcl implement means of enlisting the public’s concern and co-operation in th\v:lrting the menace of Iatent cancer. Whereas \~isceral cancer ma> occur at an>. age, the majorit!, of cases 01’ cancer of the colon and rectum are observed in patients beyond fift!. j’enrs; in this series ot rectal cancers, the extremes of :ty were thirty-one and eight?--six l\.ears; onI!- I o per cent of the patients Lvere under fort!-li1.e J ears. In gastric cancer there appears to be ;I sharp rise of such cancers in the nlnlc at :tpproximately fifty years of age. In colic and rectal cancers this rise in incidence appears to occur somewhat earlier. Until more specilic means of cletec,ting the our onI\ presence of cancer are av:lilnble, hope for more consistent earl?, recognition of cancer is the routine examination of populations in which cancer m:L! be cIe\reloping b\r precise technics of esamination. Such l;ilot cancer detection c.enters establish the \,alidit> Lvill, \ve believe, of the thesis that silent cancer can bc diagnosed. That many adults will ha\.e It is conclusion. cancer ‘ IS II foregone merely :I question of who will h:l\,cx it, in what organ and when. \Ve are concerned over making 2 more important impact upon the important problem of rectal and colic cancer than out present ~lcconiplishment suggests. It \vould be eminentlyfair to say here that the labor and the cost of operating a cancer detection c>linic ~wuld be fully justified on the scow iindings and endoscopic of the digital :Ittending ernminntions 01‘ the rectum and

396

AmcrwanJuurnald Surgcr.,,

Wangensteen,

Toon-Resection

Iower sigmoid alone. Future discoveries may probabIy make the labors of such speciaIized routine examinations less necessary We must be realistic, however, and deal with situations as we find them. The surgery of maIignant disease of the rectum and coIon can be done with little risk. The only promise for more enduring results is that a Iarger number of patients come to operation when the lesions are silent and curable by surgery. When that time comes, the conservative operation which salvages sphincteric function will have an even more important r6Ie than it has now in the management of malignancies in the middle and upper segments of the rectum. LOW

ANASTOMOSIS

MALIGNANCIES

FOK AND

EXTKA

KECTA I_

MISCELLANEOUS

CONDITIONS

Some of the most diflicult surgical problems were constituted by a miscellaneous group of patients necessitating colorectal resection, in whom restoration of intestinal continuity \yas re-established. Some of these fell in the upper group (14 to 20 cm.) and some in the lower (o to 13 cm.). There were two patients with malignant tumors of the ovary involving the rectum and uterus or vagina. One of these patients when weighed directly following the excision of the enormous tumor was 15 pounds lighter despite liberal hydration and generous administration of blood during a long operative procedure. This tumor had been explored twice elsewhere and had been said to be inoperable. In addition to the rectal resection, a jejunal and bladder resection also were necessary in this individual. The colorectnl anastomosis fell in the higher group. The other patient had undergone a previous right colectomy for cancer and a subsequent subtota1 hysterectomy. In this instance the cancer of the ovary involved the rectum, cervix and upper third of the vagina. The colorectal anastomosis was made 3 cm. from the anus; the wound heaIed by first intention without sinus or

I:I..HHU4HY. I,&

of Colon

fistula formation. It was looked upon as a palliative procedure but she has remained we11 for three years since operation with exceIIent sphincteric function. In one patient with a huge cancer of the cecum a fistulous communication existed with the rectosigmoid necessitating two simultaneous anastomoses. The lower colorectal anastomosis belonged to the upper group and the ileum was anastomosed end-to-end to the transverse colon. Table III lists the cases. An additional patient bears mention. She had tuberculous peritonitis and ;I colostomy had been performed in 1941 because of a stricture in the lower gut. At a subsequent operation an extensive tuberculous peritonitis of the pelvic colon was encountered. Considerable necrotic material in juxtaposition to the pelvic colon was intescurretted away, two simultaneous tinal resections being carried out in the right and left colon. A stricture persisted at IO cm. from the anus and ultimately a low anastomosis was carried out M)ith subsequent closure of the colostomy. Inasmuch as the colostomy was of the Devinc type, the only such colostomy ever made the closure had to be in our hospital, effected by excision of the colostomy segments and end-to-end anastomosis. Just as effective fecal deviation can be achieved bJ a single loop colostomy.‘” I’KIMAKY

KESECTIObi ULCEKATIVE

FOK

CHKONIC

COLITIS

There is a small group of patients Lvith chronic ulcerative colitis for whom ;I primary resection can be done. Amongst the operations listed herein, there were thirteen such patients. The operations performed are listed in Table XII and the distribution of the disease is outlined in Table XIII. That such resections can bc carried out in patients with segmental distribution of ulcerative colitis is understandable; a number of the patients with uIcerative colitis had that type of lesion. (Table XIII.) However, there were two patients in the group in whom the lesions of ulcerative coIitis were present through-

\‘ctc

I .\X\‘.

luc>.

L

Wangenstecn,

Toon----Resection

out the colon an d rectum, in which anastomosis of the ileum to the terminal pel~.ic colon, accompanied b,y simultaneous . escwon of the remarnder of the colon, was follo\ved b> healing of the lesions in the rectum. Ob\G)usly, the condition of the

0 -

‘l’ot:~l (II’ All (::ISCX

‘3

I~~UCOS;I of the distal rectal segment must be such that there is ;I possibility of . rcco\~er!~ ot Its function after elimination of the g-enter portion of the disease. It had been suggested that the making of an anastomosis under such circumstances kvould probably., lead to the upward migration of the dlsense from the remaining rectal segment into the lower reaches of the ileum. As a matter of fact, the reverse occurred. The disease in the rectal mucosa cleared up. In one instance this clearing process ~vas slokv as was indicated b). the persistence of :I tendency for the mucosn to bleed on proctoscopic examinations and by the continuance of diarrhea (four to six stools :I dny). In the remaining patient the i rnpro\w?ient in h ~renernl health LV:IS par-

of Colon

.4lltlr~L,,Il.I<1,1111:11 IJ >,1rgt’,v397

ailed by an eat-l>, disappearance of proctoscopic evidence of the disease from the lower rectal segment. This experience suggests that in suitable instances of ulcerative colitis, at an earlier stage in the disease, subtotal colectom,v;

with anastomosis of the ileum to the terminal pelvic colon or rectum, nia~~ lead to a disappearance of the residual lesions from the rectum. One patient \vith a segmental t\.pe of lesions in\wlving the colon as far distnll~ :IS the sigmoid was quite febrile at the tirnc of operation and had been so for Lveeks; subtotal colectomy was followed I>! imn1edint.e subsidence of fe\ver :Incl general improvement. Two patients in the group had in\ol\.ement of the entire colon Lvith n stricture in the rectum at IO cm. from the anus, with a normal mucosa in the distal rectal segColectorny with :lnastornosis I>> ment. suture to the distal rectal segment \vns carried out in these t\vo patients ivith a \.ery satisfactory result. Roth patients at-e young Momen and despite the circumstance that the bowels mo\-e three or four times ;I da, they have excellent continence and bear this burden with no complaint. In two patients presenting evidences of complete destruction of the large areas of the mucosn of both colon and rectum, :I complete colectomv and partial rectectom> together \vith es&ion of the rectal mucosa from the distal segment was carried out, pulling the ileum through at the anus. The First of these operations was done on :I :\wung school bo!- fi1.e years ago, but the lleostomy has been closed onl~ ;I few months, Despite quite satisfactory con-

398

American

Journalof Surgery

Wangensteen,

Toon-Resection

tinence, the bowe1.s move every two hours day and night because of the diarrhea1 character of the stoo1. ObviousIy, if this situation continues, the boy wouId be better off with an ileostomy bag.* In the other patient, the ileostomy has not yet been cIosed. t In order to avoid impotence which quite often attends performance of the abdominoperineal operation for excision of the rectum in the male, coIectomy and partial proctectomy with excision of the mucosa from the distal recta1 segment has been carried out in one patient (not in this series) with simultaneous establishment of an ileostomy. The abdomino-anal puII-through operation for uIcerative colitis described above was proposed for this patient but he rejected it. This operation done more than five years ago was followed by a very satisfactory resuIt with preservation of a normal sex function. SUMMARY

AND

CONCLUSIONS

of this clinic with The experience restoration of intestina1 continuity after excision of primary cancer of the rectosigmoid and rectum has been reviewed. The foIIowing conclusions seem warranted : I. For a11 lesions in the rectosigmoid area 14 to 20 cm. from the anus, the conservative operation affords the patient as satisfactory a prospect of cure as does the abdominoperineal operation. In any case, no IocaI recurrences have beenobserved after resections for cancers at this JeveI. 2. For lesions in the lower recta1 segment, at 8 cm. or Iess from the anus, the conservative operation is not a good operation for primary rectal cancer, primarily because it does not deal effectively with the invisible lateral spread of cancer as does * Sincr this WIIS written, this patient has undcrgonc vagotomy with considerable improvcmrnt. Vagotomv was done for two reasons: (I) to slow the gastric cmptying time, (2) to attempt to abolish the gnstro-ileac reff ex. t Since this paper was tvritten, Drs. Kavitch and Gabiston of Baltimore have described carrying out such a procedure on the dog.* Their article is also well illustrated. The procrdurr was dcscribcd briefly b> onr of us four ycnrs ago.‘?

of CoIon

I;ELWUAKY. IO48

the more radical abdominoperineal resection. In low-Iying lesions a fairly high incidence of Iocal recurrence stongly suggests that salvage of the rectal sphincters is accomplished at the risk of failing to cure the cancer. 3. For suitable lesions in the mid-rectal segment, above 8 cm. from the anus, the conservative operation would appear to be as satisfactory as the abdominoperineal; however, for fixed lesions, the abdominoperineal operation, undoubtedly the most radical operative procedure available, offers some advantage, the extent of which cannot yet be completely assessed. 4. The experience with the low anastomosis also is reviewed in a series of extrinsic rectal tumors as well as in a miscellany of other indications in which the lesion together with a portion of the rectum was excised with re-establishment of intestinal continuity. 5. The,experience with primary restoration of intestinal continuity after excision of subtotal Iengths of the coIon and rectum for a small, select group of patients having chronic ulcerative colitis is recounted. 6. Finally, it may be said that satisfactory rectal continence attending these operations, particularly the suture methods of restoring continuity, is quite uniform with consistent preservation of a normal sex function. The importance of preservation of the internal sphincter for the maintenance of fecal continence cannot be A satisfactoryanastooveremphasized. mosis made b.y the suture method 3 to 4 cm. above the pectinate Iine assures complete continence. REFERENCE I. B,xorc, !I. E. Evolution of sphinctcric muscle prcwrvation and rcestablishmcnt of continuit) in operative treatment of rectal and sigmoidal cancer. Sur,q., C+wc. I”* Ohsr.. 8 I : I I 3. rcj4.y. 2. BROWN, C. k. and WAKHEU, S. Visceral mctastwsis from rectal c:~rcinom:r. Surg., G~71ec. (d+ Ohst., 66: 61 I, 1938. 3. DAVID, V. C. and GILCHKIST, K. I(. Cancer of the large bowel: relation of pathology to live year cures. Ann. Surg. (in press). 4. DLKW, C. E. The surgical pathology of rectal c:Lnccr. Pror. Ryy. Sot. Med., 37: I 3r, 1q~3.

ago, but I changed is safer and nok operations by the reason that I did in those days was 0T focal recurlrncc following

to something that I Mic~~c great rn:Jjoritv of rx;teriorization rncthod. ‘TflC the end-to-end anastomosis this: I had seen man\ cxscs in the abdomiJJal mall

I do the

a Alikuficz

procedure.

‘fhvrel’orv,

would not do one. I drcl the encl-to-end niosis

ivith

or \vithout

tubes

I

;Inasto-

\vith the WII bstom>

:\IX1X’C.

Then 1 c‘anie across the K:Jnl\in nicl(lilicxtic)n 01‘ the Mikulicz tvhich appealed to 1JJv. I lo\\c\w, I belicvcd that such a proccdurc~ \I ith the yuotecf mortalit\. at that time \\as too high and, therefore, v’ith the mortalit> 01‘ I 2 per cent in those days for cntf-to-& anastomoscs, I tried the Rankin resection modilicxtion 01‘ the 1Iikulicz procedure because I t bought that I could tower it. I hax~ Ix~n :IIIIC to lowor it. I ~1ill

continue

C:ISC’ I

to do it

cfid

ha\-c

aMoniinal

uall.

Iwcaus~

I hxl

n

1\‘hat

dots

n1cans that all the rcniovecf. ‘ThC trouble operation

and

in not

:I single

rec’urrc‘n(‘c that

in

the

Inc3n?

It

glancl-bearing 11ith

evc‘n

the

the

a re;J

old

fi:rnl\in

rescrTion

operation

is that

the

rncscntcr,v

01)x iousl~

stuck

against

the

pcritoncunl

01’ the

up

is

hlil\uficz is ab-

uxlf \vheii >‘ou do tflc operation. It is you close the colostonl~-. Xf > 0Ii arc going to fiavc local rccurrencc in the nlewnter~‘, you are going to have loc:lI recurrctlc’e in the :il~tlomin:~f v-all. I liavc not seen ;I single cxx! of in?- o\vii series \z hich nicans to nlc that I c:ln tlorninal there

DISCUSSION E. .JONES (Clevelancl, Ohio) : I like to say that unfortunately too man) people in this country today think that the anastomotic operation is something new. nluch has been written about it Gthout reference to things in the past and the younger men at an! rate think that this one-stage operation is a new operation. \Vell, I looked over my figures for the past t\venty-seven years since 1920 and I ani surprised at the number of one-stage end-to-end anastornoses that I made then and \vithout coinpfcmcntar~ colostomy. UnforI‘HOMAS

\\oultl

tunatc.l>.,

many

of the people

who are writing

this subiect put complementar?; colostomy in tine print do\vn below. I say that because people have come to my cflmc and asked me if 1 do the primary rcscction. I is >‘our definition of a primar>. saitf, "M'liat resection ?” just cutting it out and sewing it “Welf, together and dropping it back ancl that is the end of it.” \\‘cll, that is tine. I did it many, rn:Jr~>~years aboul

when

do a more radic2f opmition 15ith this prcxwlure than 1 can with the encl-to-end an:1ston~osis in ;t good

ninny

\vorry

scgmcnts

about

patients

the

with

Ixcause

I,lood

peritonitis

c.ontamination

following

the;

necrosis

died

from

I do not II;I\ c to

supply. tlitf

I II tJlc> Ixlst, not

tlic

from

an open i yc‘ration ; at the suture line. If I

do not fiavc to won?- ahut that, I lwliw e that I ani going to ha\,c :I louver mortalit>. It seems to me in looking o\.er ;I II 1Ii< c\,itfence that the onf) controvcrs? is about what Icvcl you are uiffing to do an anastomosis. E;nowinp kvhat to do about malign:~nc~, it dots not make any ditfercncc. Dr. M’angensteen started out ;I I’&\ \ c;Irs :I~O Ixlicvinrr; that

\.ery

Those

tfiat

of the anus.

he said

txf;)re

Ic\~f.

could

surgery

_t cm.

\vithin

\vas long

things For

8 or

Ix tlonc IO cm.

he xvill s:r-

\verc

that

1, it h lesions

I think

clone reason

the

I3st thing

1 l)elir\,e

12, 1 j

in the

th:lt

or 10 cnl. old

tl:r? s :It

it is nothing

n(v.

400

American

Journal

ul Surgery

Wangensteen,

Toon-Resection

What is nem about it is anaston~osing thcrn below the reflection of the peritoneum and that is distinctly new. I do not have confidence in the operation. Of course, it can f)e done technically, hut I believe that one must do an awful lot of them before you can do them technically. If you take the rank and file of all ages and aft Lveights, it is an extremely tfifIicuft operation. It is a far more difficult operation than the alxforninopcrine:iI resection. I came to do the radical operation and the Jlifcs operation because I \vas fxougfit up in a sn~aff way also. Readers arc acquainted with the operations that bvere in vogue in 10 i 5 to 1925. They Lvere small operations. The Kraske operation, the pull-through operation; everything \vas done to try to save the sphincter. I \voufd rather have a patient alive and well than have him have a local recurrence. As ;\,Iiles often said, “The patient has tIeen sitting on this cancer too tong fIefore tic conies to me, and I aim not going to contribute to hini sitting on it any longer.” I am sure that the smaller operations are bound to lead to more local recurrences. As a matter of fact, there is a paradoxical figure here. Da\-id ant1 Gilchrist, three months ago, showed figures in which their local recurrence bvas 20 per cent. Now, it is something new in niafignancy and our conception of malignancy if kve are going to have a louver focal recurrence from a smaller operation. There is something \vrong with the figures. Of course, I think, as Dr. Wangensteen has said, the time is too soon and the number of’ casts too small to draw final conclusions. It is an acfmiral~fe attempt, however, to imprwe the situation and for that we give him credit. 1Iowcver. in the meantime one rmust use his o\vn ~ucfgnient as to ivhat operation fits him fxst ancl the number of patients that he think he \vill be able to benefit. I \vould say that if the perccntagc of recurrence, \vhich I think is going to be higher \vith these snialler operations, is going to he higher than with the al~donlinoperineal operation, that atone is sutlicient reason to do the abdoniinoperincaf resection lxcause there is little wise in transplanting one morbidity tvith another? A man \\,ith cancer in situ in the rectum is ten tinles better off than one \vith a perineum which finally hecomes necrotic front fxoken down rmalignancy. In his paper Dr. l+‘angensteen reported that in certain lesions of the descending colon he

of CoIon

I~l.uIlunnr, I’,.$8

may go up ant1 remove tfle entire descending colon, the spfcnic flcsure ant1 so forth ant1 anastormose the transverse colon to the rectum. He lvrote that a nlan \vflo does the abdorninoperineal operation and the hlikuficz operation cannot stand on the same stage. I certainI> cannot see how a nlan can stand on the same stage ant1 lx satisfied with getting 2 cni. heto\+ a tow rcctaf grobvth and yet remove a foot or t\vo of colon nhich is so afxolutely ancf absurdly unnecessary fxcausc you ne\‘er get glands up in the spfenic flexure frorm a gro\vth in the sigmoitl or the descending colon. The vufnerahfe area, of course, is the gland, and tfwrc is just so rmuch ~OLI can do; and if you tamper too nluch to get those glands out, you are going to have a \.ei-y high mortalit\-. The mortality, as we know, has lxcn This operation started in Ix-ought down. 1925 with ikliles, and the mortality \vas 25 to 30 per cent. In this country it was fowerecf to has heen 20, I$, 12, IO, 7, and so forth. That done by a cornf~ination of (actors that I do not ha1.c to enurneratc hew. \r’ou bon what the) are: better preoperative treatment, Iletter anesthesia, better care 0T the patient aftermxrcf, at feast until the \var emergency, all of those things. \r’ou cannot point to one factor \vhich made the tmortafity fess. Of course, I an1 small rminclecl enough to believe that the only thing that has matte a cfiffercnce in nig series is the use of steel G-e sutures. Of course, everybody laughs at it, fmt that is just my fetish. I f,elicve in my ofcf experience and my nem experience that it has immcnscfy cut clown mortality. Tocfay \vc ha1.e a series of 535 consecutive cases from 1942 to 1946 of abdotminoperineal resection in one stage lvith twenty deaths, or a mortality of 3.; per cent. Therefore, mortalit? is a thing of the past, I believe, with presentclay good hands and good hospital facilities. Ten of these tfcaths were from embolism, many of them on the day they were going home. 1’0~1 all know that story. But the one tfling 1 noufd like to ask you is in connection with this embolism mortality and what is lxing advocated in Boston. Would you be Lvilling to ligate 1,070 fenioraf veins in order to try to oft&t ten deaths frotm ctnbolisrn? I do not know that I would at this time, because I am not absolutely sold on the idea of femoral ligation, to cfo it prophylactically as advertised in all nxtfignant cases. I do not believe that I should

choose to do it in contrmplating another series Iilie this in the nest five years. ~~;ltk r st~ows a group of cases from I()do to I g~1; I I- resections were done by the R~‘likulicz technic, with six deaths. FIrhen you do I 17 of thrw c~\ses in the sigmoid, >-oil kno\5 tvhat you ‘I‘&111 I.. I I

\IOU,

‘,

0

2

0

(:;Is(.s

j

I’;

\Ior-t.

-

211

3 -',

are dealing \\ith. Pieces of the t~ladcler have been rtbmoved, the uterus may be rcmo~ed, the adnexia have been removed, oftentimes a veq large portion of the peritoneum is remo\wl. \lanv of those cases are perforated at the time I\ OII get them, so that it seems to me the sigmoitl IS reallot l,y and large a bigger problem than the rectum for these complications. A mortalit> of ; per cent in I 1- cases is perfectly satisf:lctory to me because of the tgpc of cases that they are done on and IT.C h:i\~ no IocaI re~urrc’nccs. Table 11demonstrates our group of j3i cases; tticw net-e 13- consecutive cases without :I death. This \vas entirely too long, of cwrse, and >‘our luck cannot go that way all the time, as Dr. Wangensteen has pointed out. At any rate the series \vas a long one and xe Lvere interested in attacking it from all sides to see if we couId lind any one factor which was responsible. I think we know a little bit more about cancer than \vc used to certainly; ne do not know half

dissections and the enough. The glandular information tve have had from that is \‘cr> important. However, I think the \-cnous involvement is ten times more important than the glandular involvement. In a group of 103 consecutive cases studied about ten years ago after the mcthocl oI’ Duke :IIKI David and Caller, and so forth, NC t’ountl 0s per cent of the glands involved. Ttivn after reading some articles on pathology, particularI> by \Varren, ne investigated this same group of cases again and without staining for elastic. tissue, Dr. Graham was able to tlcmonstratc venous involvement in 72 per cent of the cases, ant1 he predicted that if he \vould stai11 all ot these for elastic tissue to see Lvhcre the mnlignant cells \verc, that he bvould probably do it in :t higher percentage of cases. \\‘hat does that mean? When you do a low anastomosis, J 011 must tear through the mesentery fat.. ‘I’OU map get 2 cm. belo\\ a good mucosa, but 1 Ix4ivvc the trouble is in the surrouncling trssurs, in the surrounding fat. Dr. Graham, I must say, laid more emphasis on invasion of the mcsenteric fat as :I prognostic thing than glandular involvement. I believe that it is true. ‘fhc venous involvement is the important one. I believe unless you get veq far around the growth, you are going to get local rec’urrc‘ncc from these cells in the veins. .lOHr\; \I. \$‘.%~-cH (Kochcster, 3linn.i: In attempting to curr malignancy I+ means 01’ operation three important factors stiould lx given consideration by the surgeon: First, does the operation he proposes to use can-\. the best chance of cure for the patient of an) 01‘ the procedures available; second, is the risk 01’ operation reasonable or does it out\veigh the chances of cure; and third, is the patient left in a normal condition following surgery arid able to carry on his work lvithout impvtlient

or

embarrassment. Because in the past so patients have of necessity had permanent :tnd temporary colostomies i’ollo~~ing operations for cancer of the colon and rectum, it is titting and timely that \ve periodic;1ll> rc’vic’v our operatic cl procedures to see if more patients stomxs ivithout cannot he spared colonic sacrificing a high curability rate or a low operative mortality. In the past ten gears we have seen the staged procedures for resection of the abdominal colon gradually give \vay to the single stage operation without temporary colostom! esccpt in the nwny

402

~~~~~~~~~~~~ hlrnd

(4 surgcly

\tra

ngensteen,

Toon --Resection

fuw ol’ olxtruction.

Right htw~icolectonly has in one stage at the Rlayo Clinic for several years \vith immediate primary anastomosis \vith a mortality of 2 to 3 per cent. In 1946 eighty such resections were carried out In the transverse without a hospital fatality. lxmi

done

teriorizcd ant1 excludes the lower group, thcrc were I 17 patients with a 4 per cent hospital mortality. I do not believe that this mortality could have f>een lowered by use of the exteriorization procedure. The length of hospital stay for the single stage procedure has averaged one-

TABLE INCIDENCE

OF

IIE?‘HOGHADE

KODAL

METASTASIS KEVIEW

IN

OF

of Colon

I CARCIXOMA

OF

RECTUM

AND

RECTOSICMOID:

LITERATURE

T Positive NV&S (Cases)

NO&S lnvolvrd b&w Lesion (Cases)

Distancc below Lesion

Sitr ot’ I.csion

02

Rcctosignwitl

22

Alnpulla (6 cm.)

Rrctosigmoid

Icolon and descending colon to the lower sigmaid resection \Vith primary anastomosis has been done, as Dr. Wnngenstcen has shown, \vith a mortality 0T 5 per cent and less. In the past Ii\,c years on my own service I()- resections \vith primar\- anastomosis have been clone in the left colon with a hospital mortality of 5.5 per cent. This figure includes resections for carcinoma of the rectosigmoid, upper rectum and lo\f,er sigmoid. If one considers only the group of lesions that couIc1 have been ex-

third that of the multiple stage. This is no small economic factor, especially if one elects to carry out palliative resections for obviousI> incurable disease. Most of the controversy in recent years concerning rectal surgei-)- has been (I j Is the sphincter conserving operation radical enough for cure whether it be done by anterior resection as advocated by Dixon and Wangensteen or by the pull-through procedure popularized by Babcock and Bacon? (2) Is the operative

mortality low enough and the functional result suflkient to justify these sphincter conserving operations? First, as far as cure is concerned with these operations, I am satisfied personally that they arc just as c.urati\.e as the Rliles procedure for Tr\ULII II

lesions

kvhere the lower edge ot’ the cancer is ; cm. or more above the pectinate fine. The work of Clover on retrograde spread (Table I) predicted such would be the case and this has ken substantiated by Dr. Dixon’s fivevcar cut-c rate following anterior resection. i Tabfc II.) Second, the operative mortality of :tnterior resection is approaching that of the Miles operation but because of the suture fine undoubtedly will always f>e a trifle higher even in the hands of those with considerable expericnw. The puff-through procedure, however, can be done \vith just as low a mortality as the Miles and in nix own experience of approximately one hundred there has been one hospital death. Anal contro1 after even low anterior resection has been excellent. Following the puff-through operation most patients do not have perfectly normal control and few are able to control Hatus. The majority, however, rarefy soil themsel\-es unless diarrhea appears and all patients even those with the prefer the procedure, most unsatisfactory rcsuIts, to an abdominal colostomy. OWEN II. W'ANGENSTEEN (closing): All of us in a sense are surgical Fausts. I am not thinking of those \vho sell themselves for thirty pieces of silver or a mess of pottage. I am taking about compromises which surgeons are willing

make. Dr. Jones would have us blefirve that he affects fess interest in preservation of fecal continence and sexual function than he does in the contour of the female breast. ‘That is an interesting attitude of mind. Dr. Jones apparently linds no difTicuft,v in clefending the necessity of performing the akdominoperineaf operation in all patients with cancer of the iliac colon and rcctosigmoid in which the \likuficz procedure cannot IX done, an admission suggesting perhaps that he is a IXtter master ol the ahdominoperineaf operation than hc is of primar?; resection. Certainly the tinle has come I;)r esperienccd surgeons to cxtcriorizc the cxteriorization operation in dealing with cancer of the colon. In practiced hands, thr two operations can he clone at the same risk with an important salvage in hospital sta,v and expense to the patient for whom primary resection is done. I grant freely that I have overc?ctencIed m!self in the anxiety to please :t patient who \vishes her sphincteric function saved. Like the young fads in the musical comedy “Oklahoma”, I have found it difficult now ;tnd then to say no-but I am learning. With reference to the recurrences lvhich we have observed after the anastomotic. operation, it perhaps is not out of pfacc to emphasize that these have not been in the IXNYI wall on the contrary, the rccurrfnccs primarily; first made their appearance outside the I,owef involving it secondarily. In other words, what MY interpreted as a Dukes’ group .A case, on occasion f~cfonged in reality to Dukes’ group c, in that, in\:isilk latera spread ufwatl?: had occurrecf at the time of the initial operation but had not been identified as such. Our own experience suggests quite dctinitc:fv that for the upper group (14 to 20 cm. Tram the anus) the anastomotic operation holds out iust as much promise of cure as does the abdominoFor patients kvith lesions perineal operation. fess than 8 cm. f’rom the anus MY have given up the anastornotic procedure hccausr of the greater hazard of focal recurrence than follo\vs the al~clominoperir~eaf operation. The controversial group, it seems to mc, is the intermediate group betsveen 9 and 13 c’m. from the anus. There is no debate about the superiorit,v of the ahdominoperineal operation I;)r this group; that is granted. The qucs,tion is: How much better is it from the standpoint of curahillty of cancer than the anastotmotic. proto

cedure? This is the group in lvhich some case selection may have to be done. Among thirtgtwo patients with lesions at this level for lvhom an anastornotic procedure \vas carried out, local recurrence ~2~s observed fly us twice (6.3 per cent). \i’ith proper cast selection I believe that the anastomotic procedure with satisfactory removaf of’the lymphatic drainage area can be done in a large number of patients Lvith lesions at this level. Dr. \Vaugh’s figures are excellent. In fact, the,v are so good that one cannot help flut conclude that some selection must have occurred in his groups. \iVith reference to the kind of anastomotic operation to fx carried out our experience suggests dcfinitef\- that the direct suture carried out as a one-stage procedure from the abdomen is the Ilest operation. For anastomoses made at 8 cm. or more from the anus drainage is rarely necessary and a supplerncntal external decompress&e vent is not nccessarJ-. With elimination of the anastomotic procedure for lesions lying less than 8 cm. from the anus the single row direct suture method becomes, save for a few exceptions, the standard procedure. A young woman \vill put up with less complaint on this score, getting rid of an abdominal ifeostomg, than will a young man. I kno\v young marriagahle girls n-ho had an ileostomy for some time and they are closed. Even though they have four or five stools a day, they make no complaint about it. I suppose maybe the male is a more complaining creature. He will suggest two or three stools a day is a burden for him to bear. Wilf you read the questions and I \vifl tr> to ans\ver them one by one, if I can. DR. AULT: Doctor, I understand this is in a research process. I am wondering how man3 anastomoses between ileum and involved rectum or rectosigmoid in cases of ulcerative colitis have held up for how long. DR. WAGENSTEEN: Obviously, an attempt to conserve the rectum or part of it in the type of

case demonstrated b,v Dr. Ault on the screen LvouId fx I’oolhartly. If one is going to anastomose the ileum to a residual rectal segment, that segment should be free of ulcerative colitis or have only punctate hemorrhages in the mucosa without e\,idence of destruction of the mucosa. DR. AULT: Thank you, Dr. LVangensteen. We want to make this clear to evcrgbody. Ho\\ many have had to be converted f,ack to ileostomg? DR. WANGFNSTEEN: That is easy to anslyer -none. DR. AULT: What complications, stricture, abscesses and what morbidity have attended this procedure of anastomosing the ikum to involved rectum or rectosigmoid? DR. ~~‘ANCANSTEEN: There has Jxw no mortality either accompanJ.ing operation or since operation. IVhereas some of’ the patients \Vith mild evidences of disease in the distal rectal segment have continued to ha\:e some diarrhea, it has been gratiI.ying to ofxerj~e that extirpation of 83 to ()o per cent of the extent of the disease has permitted the lesions in the residual rectal segment to improve. ,Iloreover, migration of the disease into the ileum al’ter such anastomoses has not been observed. OnI\ one patient has f>ecn operatecl upon in a febrile state. To that patient \ve gave streptomycin, sulfasusidinc and penicillin prior to operation. A one-stage operation was done anastomosing the ileum to uninvolved rectum, excising the involved colon fletween. The patient convalesced uneventfuII~and left the hospital about a lveek after operation. Some of the matters discussed today obviously are controversial in nature; horvever, we cannot resoIve our differences by debate flut rather by analyzing our experiences criticall! and recording them truthfully. That is what Dr. Toon and I have tried to do in this paper. Time is the final arbiter of all things. ./ Until she has given her answer, let us be tolerant ot our honest differences of opinion.