Electrocoagulation
as Primary Therapy for Rectal Carcinoma
Eugene P. Salvatl, MD, FACS, Plainfield, New Jersey Robert J. Rubin, MD, FACS, Plainfield, New Jersey
The application of electrocoagulation for the destruction of a rectal carcinoma was first described by Byrne in 1889 and then later reintroduced by Wassink [I] and Strauss et al [Z]. Reports published on this subject [I, 3-81 and other smaller series of patients [9-111 have all attested to the effectiveness of this form of therapy. Presented herein is a follow-up study to an earlier report [7]. A total of seventy patients have been treated by electrocoagulation over a thirteen year period. Nineteen patients were treated for palliation and thus will only be briefly considered. Fifty-one patients were considered curable, and of these, forty-seven have been followed for more than one year. Also evaluated are the results of primary abdominoperineal resection in thirty-two patients plus seventeen patients treated by electrocoagulation who subsequently were converted to abdominoperineal resection for a total of forty-nine abdominoperineal resections during this same period. Two patients were lost to follow-up, thus making forty-seven abdominoperineal resections in all. Because we realize the controversy that this subject brings about, our results are compared only with our own, not with those of others by whom abdominoperineal resections have been performed. All of these operations were performed by or under the direction of either of us primarily at Muhlenberg Hospital and to a lesser degree at Raritan Valley Hospital and John Fitzgerald Kennedy Hospital. Our statistics are detailed for both electrocoagulation and abdominoperineal resections. We realize that the series is small but we consider it large enough to draw inferences and suggest therapeutic guidelines.
From the Division of Colon and Rectal Surgery, Muhlenberg Hospital, Plainfield, New Jersey. k-print requests should be addressed to Eugene P. Salvati, MD, 1010 Park Avenue, Plainfield, New Jersey 07060.
Material and Methods Technic. Many different technics have been described by other authors [2,3,8]. We will simply present ours. Electrocoagulation is performed in the lithotomy position under light general anesthesia. To improve anal relaxation and to minimize the depth of anesthesia, local infiltration of 50 cc of 0.25 per cent bupivicaine with 1:200,000 epinephrine to which has been added 300 turbidity units of hyaluronidase is carried out. All electrocoagulation is performed endoscopically via the 23 or 27 mm Welch-Allyn
sigmoidoscope or by means of a recently developed operating proctoscope (Karl Storz Endoscopy America Inc, 658 South San Vicente Blvd, Los Angeles, CA 90048). This instrument is 15 cm long and 40 mm in diameter. It has a 90° oblique end, fiberoptic illumination that can be adapted to any available fiberoptic light source, and a channel for removal of smoke built into the instrument. This instrument has facilitated and simplified the coagulation. Lateral sphincterotomy is occasionally necessary before the’instrument can be introduced into the rectum. The Cameron electrosurgical unit is used with the bipolar coagulating current. No cutting current is employed. The large 5 mm Cameron electrocoagulating and suction tip is used. The electrode is applied to the entire surface of the tumor until the tumor has turned white and additionally a 1 cm halo of normal mucosa is destroyed about the tumor. All charred tumor is then removed with angulated biopsy forceps and less frequently with a sharp uterine curette. The process is repeated until all tumor has been destroyed both visually and where feasible by palpation. The latter is a most helpful and reliable guide to the efficacy of tumor destruction. Posteriorly electrocoagulation can be quite radical and tissue destruction can extend to the presacral fascia. Anteriorly one must be more cautious. The process is tedious and requires at least 60 to 75 minutes to complete. Good suction is essential. The extensive heat produced mandates oral use of an anesthetic. Postoperatively the patients become febrile and are treated with antipyretics. Septicemia has not occurred. Pain is minimal and the patients are discharged in three to five days. Phthalylsulfathiazole, 1.5 gm four times a day, is given for two weeks along with a stool softener. The rectal 563
Salvati and Rubin
wound heals by secondary intention. All patients are followed at monthly intervals for the first year. Any questionable area is rebiopsied and if positive for carcinoma, the patient is returned to the hospital for repeat electrocoagulation. If more than three electroagulations are necessary, then we believe abdominoperineal resection should be performed in the acceptable risk patient. The palpation of hard satellite nodes adjacent to the electrocoagulation site at any time is an indication for abdominoperineal resection. One should not persist in continuing electrocoagulation when it becomes obvious that it is failing to control the tumor. Indications. Electrocoagulation in our hands is used for any adenocarcinoma in all good risk patients involving any wall of the rectum below the 7.5 cm level from the anal verge when one half or less of the circumference of the rectum is involved. Any tumor above 7.5 cm is treated by low anterior resection. Higher and larger lesions can be treated in the poor risk patient. If the lesion is fixed to the presacral fascia or if the rectovaginal septum is involved, abdominoperineal resection should be performed when the patient is medically sound. If the lesion involves more than half the circumference of the rectum, in the good risk patient abdominoperineal resection should be carried out because a postcoagulation stricture is likely to occur. This in itself might necessitate colostomy. Most strictures are managed by repeated dilations in the office. In the poor risk patients, larger lesions have been treated. The ideal lesion for elec-
trocoagulation is moveable, is less than 7.5 cm from the anal verge, and involves as much as half the rectal wall. As can be seen by the stated parameters, whenever possible, electrocoagulation is applied selectively, fitting the method of management to the patient rather than universally applying either abdominoperineal resection or electrocoagulation for all patients. Results Electrocoagulatlon
Of the forty-seven patients followed for more than one year, twenty-three survived from one to ten years (9,l year; 2,2 years; 3,3 years; 3,4 years; 1,6 years; 1, 7 years; 2, 8 years; 1, 9 years; 1, 10 years). Three patients, aged forty-five, ninety-one, and eighty-six years, died at three, six, and seven years, respectively, with no evident tumor. Survival rate was thus 48.9 per cent. There were twenty-four electrocoagulation failures: seven patients (14.8 per cent) died, with an average survival of 1.5 years, and seventeen underwent resection (13 abdominoperineal resections, 4 anterior resections), two of whom died postoperatively. Of the fifteen patients who survived delayed resection, eight (17 per cent) are dead with disease and seven (14 per cent) are alive. All eight patients who died had positive nodes at surgery. Six of the seven patients alive after surgery had negative nodes 584
in the resected specimen. The one patient with positive nodes now has liver metastases. The average survival in those patients with positive nodes is sixteen months, with one patient surviving forty months. For the total patients requiring surgical resection (17), the survival rate was 41 per cent (7). This implies that failure of electrocoagulation does not jeopardize the patient’s opportunity to survive further radical surgery. Seven of the seventeen patients were operated on within three months of their original electrocoagulation. One can often tell at the first electrocoagulation whether abdominoperineal resection will be necessary later. The number of electrocoagulation sessions ranged from one to twelve, but the majority of patients (36) had only one treatment and forty-seven of the fiftyone patients underwent three or less electrocoagulation treatments. Ages ranged from thirty-eight to eighty-seven years. Twenty-four of the fifty-one patients (47 per cent) treated with electrocoagulation were more than seventy-one years of age, at which point.the operative mortality from abdominoperineal resection is acknowledged to be quite high by all authors. None of our electrocoagulation patients died intra- or postoperatively. The size of the lesion in our fifty-one varied, occupying one eighth of the bowe,l wall circumference (3 patients), one fourth (14), one third (17), one half (15), or two thirds (2). The distance from the anal verge to the tumor was less than 7.5 cm in thirty-six patients, 7.5 to 12 cm in eleven patients, and greater than 12 cm in four patients. These last four patients were all elderly and considered very poor risks. We caution that the electrocoagulation of tumors more than 12 cm from the anal verge can be dangerous and should only be carried out selectively. Tumors were almost equally distributed between the anterior and posterior wall of the rectum. Forty-one patients had exophytic tumors, whereas ten had a flat lesion. Contrary to the findings of others, there was little difference in survival rate between the exophytic and flat lesions. No malignant polyps or malignant villous tumors are included in our series. Electrocoagulation was performed as a palliative procedure in 19 patients, twelve of whom were more than seventy-five years old. The mean average survival time was 6.8 months. A colostomy was avoided in all but three of these patients. Complications. Overall, including those treated for palliation as well as for cure, seventy patients were treated by electrocoagulation. No deaths occurred as a result of the treatment in these seventy patients. Five patients (7.1 per cent) had postoperative hemThe Amorlcan Journal 01 Stqwy
Electrocoagulation
for Rectal Carcinoma
orrhage, three of whom ceased bleeding spontaneously. Two patients (2.8 per cent) required repeat electrocoagulation to cont,rol the bleeding, but none required proctectomy. Three patients (4.2 per cent) sustained third degree electrical burns of the skin due to improper grounding of the equipment. These burns were as large as 5 cm in diameter and occurred where the grounding plate touched the buttock or back. One patient (1.4 per cent) had a perirectal abscess, requiring incision and drainage. He healed without fistula formation. Five patients (7.1 per cent) had a stricture that required prolonged dilatation in the office. One patient required a colostomy for perforation when a circumferential tumor was split by the scope passing through it, thus tearing the bowel lengthwise and resulting in a perforation at the peritoneal reflection. This eighty-four year old male died twelve months later of his disease. A second perforation occurred in a patient who had two lesions, one in the sigmoid and one in the rectum. The sigmoid lesion was not discovered until laparotomy and only after it was electrocoagulated inadvertently. This patient underwent colostomy and then abdominoperineal resection later. He was our only survivor with proved nodal disease, but he now has liver metastasis.
ease. This represents a 51 per cent failure rate among our patients undergoing curative abdominoperineal resection. Of these thirty-seven patients, the overall uncorrected survival rate extending from one to eight years was 46 per cent. Furthermore, of the eighteen patients resected for cure who did not have lymph node involvement, two died in the immediate postoperative period and another died after two and a half years. The remaining fifteen patients are alive and thirteen of them (72 per cent) are free of disease. Of the nineteen patients resected for cure who had positive lymph nodes, one died in the immediate postoperative period, twelve died over a one to four year period, and only four of the six survivors are alive and free of disease, representing a 21 per cent cure rate. Our results are comparable with those of others [13]. The shortest hospital stay in the abdominoperineal group was fifteen days. The mean length of stay was 23.5 days and twenty of the forty-seven patients who were hospitalized remained in the hospital for more than twenty-one days. Our operative mortality (3 of 47 patients) was 6 per cent. Thirty-four of the forty-seven patients (72 per cent) had a complicated postoperative course and thirteen of the thirty-four (38 per cent) had multiple complications.
Abdominoperlneal Resections
Comments
Forty-seven patients with adenocarcinoma of the distal rectum underwent abdominoperineal resection during this same period. All cases of squamous cell, cloacogenic (anal duct) carcinoma, melanoma, and other anorectal malignancies different from adenocarcinoma were excluded from this series. Of the forty-seven patients, thirty-seven underwent curative resection-that is, there was no evidence of disease beyond the site of resection or its draining lymph nodes. In the curative group nineteen had positive lymphadenopathy and eighteen had no nodal metastasis. Among the ten “palliative” resections performed, eight were thought to be curative until the time of laparotomy when metastatic implantation of the peritoneal cavity or of the liver was noted. In the palliative group of ten, only three patients survived for more than ten months (range, 5 to 40 months) [12]. The eight lesions found to be incurable would have fallen into our coagulation for “cure” group because laparotomy was required to prove the presence of distal spread. Their liver scans showed nothing abnormal and their bilirubin, lactic dehydrogenase, and alkaline phosphatase values were all within normal limits. Thirty-seven patients underwent curative abdominoperineal resection. Fifteen patients (40 per cent) died and four (11 per cent) are alive with dis-
The group of patients who underwent abdominoperineal resection is comparable numerically with our group undergoing electrocoagulation and is comparable regarding length of follow-up. Included in the earlier group of patients undergoing abdominoperineal resection are some small and exophytic lesions as well as some of the more extensive lesions treated later on. The influence upon mortality by excluding lesions of greater than half the bowel circumference in our electrocoagulation group is probably balanced by the more advanced age of the electrocoagulation group as compared with the abdominoperineal resection group. Furthermore, Dukes [14] has shown that size has little prognostic value in colonic carcinoma. No specific conclusions can be drawn from our comparative study, but inferences can be made. The uncorrected survival statistics in both groups seem to be identical-48 per cent in the coagulation group and 46 per cent in the abdominoperineal resection group. Whether electrocoagulation stimulates an antibody response as described by Strauss [2] remains a moot point. Studies are now in progress to determine whether this is so. We strongly believe that large numbers of patients need not undergo abdominoperineal resection in order to receive the maximum benefit of medical care for the treatment of carcinoma of the rectum.
Volume 132, November 1876
585
Salvati
and Rubin
Summary
The survival of forty-seven patients with cancer of the rectum treated by electrocoagulation is compared with thirty-seven patients treated by abdominoperineal resection. The one to ten year survival for the electrocoagulation group was 48 per cent and the one to eight year survival for the abdominoperineal resection group was 46 per cent. We believe that electrocoagulation when selectively applied has a place in the management of cancer of the rectum. References 1. Wassink WF: The curative treatment of carcinoma recti by means of electrocoagulation and radium. Arch Chir Neerl 8: 313, 1956. 2. Strauss A, Strauss S, Crawford R. Strauss H: Sugical dtathermy of carcinoma of the rectum. JAMA 104: 1460. 1935. 3. Ferguson LK: Treatment of carcinoma of the rectum and rectosigmoid by electrocoagulation. New lnt C/in 1: 199, 1940.
588
4. Kergin FG: Diathermy fulguration in the treatment of certain cases of rectal carcinoma. Can Med Assoc J 69: 14, 1953. Klok PAA: The treatment of some forms of rectal cancer by electrocoagulation. Arch C/in Neerll6: 173, 1964. Madden JL. Kandalaft S: Electrocoagulation in the treatment of cancer of the rectum. Ann Surg 174: 530, 197 1. Swerdlow DB, Salvati EP: Electrocoagulation of cancer of the rectum. Dis Colon Rectum 15: 228, 1972. Crile G, Turnbull RB: The role of electrocoagulation in the treatment of carcinoma of the rectum. Surg Gm/ obsfef 135: 391.1972. 9. Phillips DL. Edmond JA: Fulguration as primary treatment of cancer of the rectum. Maine h&d Assoc 62: 236, 1971. 10. Poirier A, Poirier B: Sur I’electrocoagulation dans Ia cancer du rectum. Gaz MedFrance 62:1525, 1955. 11. Jackman RJ: Conservative management of selected patients with carcinoma of the rectum. Dis Colon Rectum 4: 429, 1961. 12. Bordos DC, Baker RR. Cameron JL: An evaluation of palliative abdominoperineal resection for carcinoma of the rectum. Surg Gynecol Obstet 139: 73 1, 1974. 13. Gilbertsen VA: The results of the surgical treatment of cancer of the rectum. Surg Gynecol Obstet 114: 313, 1962. 14. Dukes C: Histological grading of rectal cancer. Rot R See Med 30: 371, 1937.
lho Amafkm
Journal 04 Surfpry
as Primary Therapy for Rectal Carcinoma
Eugene P. Salvatl, MD, FACS, Plainfield, New Jersey Robert J. Rubin, MD, FACS, Plainfield, New Jersey
The application of electrocoagulation for the destruction of a rectal carcinoma was first described by Byrne in 1889 and then later reintroduced by Wassink [I] and Strauss et al [Z]. Reports published on this subject [I, 3-81 and other smaller series of patients [9-111 have all attested to the effectiveness of this form of therapy. Presented herein is a follow-up study to an earlier report [7]. A total of seventy patients have been treated by electrocoagulation over a thirteen year period. Nineteen patients were treated for palliation and thus will only be briefly considered. Fifty-one patients were considered curable, and of these, forty-seven have been followed for more than one year. Also evaluated are the results of primary abdominoperineal resection in thirty-two patients plus seventeen patients treated by electrocoagulation who subsequently were converted to abdominoperineal resection for a total of forty-nine abdominoperineal resections during this same period. Two patients were lost to follow-up, thus making forty-seven abdominoperineal resections in all. Because we realize the controversy that this subject brings about, our results are compared only with our own, not with those of others by whom abdominoperineal resections have been performed. All of these operations were performed by or under the direction of either of us primarily at Muhlenberg Hospital and to a lesser degree at Raritan Valley Hospital and John Fitzgerald Kennedy Hospital. Our statistics are detailed for both electrocoagulation and abdominoperineal resections. We realize that the series is small but we consider it large enough to draw inferences and suggest therapeutic guidelines.
From the Division of Colon and Rectal Surgery, Muhlenberg Hospital, Plainfield, New Jersey. k-print requests should be addressed to Eugene P. Salvati, MD, 1010 Park Avenue, Plainfield, New Jersey 07060.
Material and Methods Technic. Many different technics have been described by other authors [2,3,8]. We will simply present ours. Electrocoagulation is performed in the lithotomy position under light general anesthesia. To improve anal relaxation and to minimize the depth of anesthesia, local infiltration of 50 cc of 0.25 per cent bupivicaine with 1:200,000 epinephrine to which has been added 300 turbidity units of hyaluronidase is carried out. All electrocoagulation is performed endoscopically via the 23 or 27 mm Welch-Allyn
sigmoidoscope or by means of a recently developed operating proctoscope (Karl Storz Endoscopy America Inc, 658 South San Vicente Blvd, Los Angeles, CA 90048). This instrument is 15 cm long and 40 mm in diameter. It has a 90° oblique end, fiberoptic illumination that can be adapted to any available fiberoptic light source, and a channel for removal of smoke built into the instrument. This instrument has facilitated and simplified the coagulation. Lateral sphincterotomy is occasionally necessary before the’instrument can be introduced into the rectum. The Cameron electrosurgical unit is used with the bipolar coagulating current. No cutting current is employed. The large 5 mm Cameron electrocoagulating and suction tip is used. The electrode is applied to the entire surface of the tumor until the tumor has turned white and additionally a 1 cm halo of normal mucosa is destroyed about the tumor. All charred tumor is then removed with angulated biopsy forceps and less frequently with a sharp uterine curette. The process is repeated until all tumor has been destroyed both visually and where feasible by palpation. The latter is a most helpful and reliable guide to the efficacy of tumor destruction. Posteriorly electrocoagulation can be quite radical and tissue destruction can extend to the presacral fascia. Anteriorly one must be more cautious. The process is tedious and requires at least 60 to 75 minutes to complete. Good suction is essential. The extensive heat produced mandates oral use of an anesthetic. Postoperatively the patients become febrile and are treated with antipyretics. Septicemia has not occurred. Pain is minimal and the patients are discharged in three to five days. Phthalylsulfathiazole, 1.5 gm four times a day, is given for two weeks along with a stool softener. The rectal 563
Salvati and Rubin
wound heals by secondary intention. All patients are followed at monthly intervals for the first year. Any questionable area is rebiopsied and if positive for carcinoma, the patient is returned to the hospital for repeat electrocoagulation. If more than three electroagulations are necessary, then we believe abdominoperineal resection should be performed in the acceptable risk patient. The palpation of hard satellite nodes adjacent to the electrocoagulation site at any time is an indication for abdominoperineal resection. One should not persist in continuing electrocoagulation when it becomes obvious that it is failing to control the tumor. Indications. Electrocoagulation in our hands is used for any adenocarcinoma in all good risk patients involving any wall of the rectum below the 7.5 cm level from the anal verge when one half or less of the circumference of the rectum is involved. Any tumor above 7.5 cm is treated by low anterior resection. Higher and larger lesions can be treated in the poor risk patient. If the lesion is fixed to the presacral fascia or if the rectovaginal septum is involved, abdominoperineal resection should be performed when the patient is medically sound. If the lesion involves more than half the circumference of the rectum, in the good risk patient abdominoperineal resection should be carried out because a postcoagulation stricture is likely to occur. This in itself might necessitate colostomy. Most strictures are managed by repeated dilations in the office. In the poor risk patients, larger lesions have been treated. The ideal lesion for elec-
trocoagulation is moveable, is less than 7.5 cm from the anal verge, and involves as much as half the rectal wall. As can be seen by the stated parameters, whenever possible, electrocoagulation is applied selectively, fitting the method of management to the patient rather than universally applying either abdominoperineal resection or electrocoagulation for all patients. Results Electrocoagulatlon
Of the forty-seven patients followed for more than one year, twenty-three survived from one to ten years (9,l year; 2,2 years; 3,3 years; 3,4 years; 1,6 years; 1, 7 years; 2, 8 years; 1, 9 years; 1, 10 years). Three patients, aged forty-five, ninety-one, and eighty-six years, died at three, six, and seven years, respectively, with no evident tumor. Survival rate was thus 48.9 per cent. There were twenty-four electrocoagulation failures: seven patients (14.8 per cent) died, with an average survival of 1.5 years, and seventeen underwent resection (13 abdominoperineal resections, 4 anterior resections), two of whom died postoperatively. Of the fifteen patients who survived delayed resection, eight (17 per cent) are dead with disease and seven (14 per cent) are alive. All eight patients who died had positive nodes at surgery. Six of the seven patients alive after surgery had negative nodes 584
in the resected specimen. The one patient with positive nodes now has liver metastases. The average survival in those patients with positive nodes is sixteen months, with one patient surviving forty months. For the total patients requiring surgical resection (17), the survival rate was 41 per cent (7). This implies that failure of electrocoagulation does not jeopardize the patient’s opportunity to survive further radical surgery. Seven of the seventeen patients were operated on within three months of their original electrocoagulation. One can often tell at the first electrocoagulation whether abdominoperineal resection will be necessary later. The number of electrocoagulation sessions ranged from one to twelve, but the majority of patients (36) had only one treatment and forty-seven of the fiftyone patients underwent three or less electrocoagulation treatments. Ages ranged from thirty-eight to eighty-seven years. Twenty-four of the fifty-one patients (47 per cent) treated with electrocoagulation were more than seventy-one years of age, at which point.the operative mortality from abdominoperineal resection is acknowledged to be quite high by all authors. None of our electrocoagulation patients died intra- or postoperatively. The size of the lesion in our fifty-one varied, occupying one eighth of the bowe,l wall circumference (3 patients), one fourth (14), one third (17), one half (15), or two thirds (2). The distance from the anal verge to the tumor was less than 7.5 cm in thirty-six patients, 7.5 to 12 cm in eleven patients, and greater than 12 cm in four patients. These last four patients were all elderly and considered very poor risks. We caution that the electrocoagulation of tumors more than 12 cm from the anal verge can be dangerous and should only be carried out selectively. Tumors were almost equally distributed between the anterior and posterior wall of the rectum. Forty-one patients had exophytic tumors, whereas ten had a flat lesion. Contrary to the findings of others, there was little difference in survival rate between the exophytic and flat lesions. No malignant polyps or malignant villous tumors are included in our series. Electrocoagulation was performed as a palliative procedure in 19 patients, twelve of whom were more than seventy-five years old. The mean average survival time was 6.8 months. A colostomy was avoided in all but three of these patients. Complications. Overall, including those treated for palliation as well as for cure, seventy patients were treated by electrocoagulation. No deaths occurred as a result of the treatment in these seventy patients. Five patients (7.1 per cent) had postoperative hemThe Amorlcan Journal 01 Stqwy
Electrocoagulation
for Rectal Carcinoma
orrhage, three of whom ceased bleeding spontaneously. Two patients (2.8 per cent) required repeat electrocoagulation to cont,rol the bleeding, but none required proctectomy. Three patients (4.2 per cent) sustained third degree electrical burns of the skin due to improper grounding of the equipment. These burns were as large as 5 cm in diameter and occurred where the grounding plate touched the buttock or back. One patient (1.4 per cent) had a perirectal abscess, requiring incision and drainage. He healed without fistula formation. Five patients (7.1 per cent) had a stricture that required prolonged dilatation in the office. One patient required a colostomy for perforation when a circumferential tumor was split by the scope passing through it, thus tearing the bowel lengthwise and resulting in a perforation at the peritoneal reflection. This eighty-four year old male died twelve months later of his disease. A second perforation occurred in a patient who had two lesions, one in the sigmoid and one in the rectum. The sigmoid lesion was not discovered until laparotomy and only after it was electrocoagulated inadvertently. This patient underwent colostomy and then abdominoperineal resection later. He was our only survivor with proved nodal disease, but he now has liver metastasis.
ease. This represents a 51 per cent failure rate among our patients undergoing curative abdominoperineal resection. Of these thirty-seven patients, the overall uncorrected survival rate extending from one to eight years was 46 per cent. Furthermore, of the eighteen patients resected for cure who did not have lymph node involvement, two died in the immediate postoperative period and another died after two and a half years. The remaining fifteen patients are alive and thirteen of them (72 per cent) are free of disease. Of the nineteen patients resected for cure who had positive lymph nodes, one died in the immediate postoperative period, twelve died over a one to four year period, and only four of the six survivors are alive and free of disease, representing a 21 per cent cure rate. Our results are comparable with those of others [13]. The shortest hospital stay in the abdominoperineal group was fifteen days. The mean length of stay was 23.5 days and twenty of the forty-seven patients who were hospitalized remained in the hospital for more than twenty-one days. Our operative mortality (3 of 47 patients) was 6 per cent. Thirty-four of the forty-seven patients (72 per cent) had a complicated postoperative course and thirteen of the thirty-four (38 per cent) had multiple complications.
Abdominoperlneal Resections
Comments
Forty-seven patients with adenocarcinoma of the distal rectum underwent abdominoperineal resection during this same period. All cases of squamous cell, cloacogenic (anal duct) carcinoma, melanoma, and other anorectal malignancies different from adenocarcinoma were excluded from this series. Of the forty-seven patients, thirty-seven underwent curative resection-that is, there was no evidence of disease beyond the site of resection or its draining lymph nodes. In the curative group nineteen had positive lymphadenopathy and eighteen had no nodal metastasis. Among the ten “palliative” resections performed, eight were thought to be curative until the time of laparotomy when metastatic implantation of the peritoneal cavity or of the liver was noted. In the palliative group of ten, only three patients survived for more than ten months (range, 5 to 40 months) [12]. The eight lesions found to be incurable would have fallen into our coagulation for “cure” group because laparotomy was required to prove the presence of distal spread. Their liver scans showed nothing abnormal and their bilirubin, lactic dehydrogenase, and alkaline phosphatase values were all within normal limits. Thirty-seven patients underwent curative abdominoperineal resection. Fifteen patients (40 per cent) died and four (11 per cent) are alive with dis-
The group of patients who underwent abdominoperineal resection is comparable numerically with our group undergoing electrocoagulation and is comparable regarding length of follow-up. Included in the earlier group of patients undergoing abdominoperineal resection are some small and exophytic lesions as well as some of the more extensive lesions treated later on. The influence upon mortality by excluding lesions of greater than half the bowel circumference in our electrocoagulation group is probably balanced by the more advanced age of the electrocoagulation group as compared with the abdominoperineal resection group. Furthermore, Dukes [14] has shown that size has little prognostic value in colonic carcinoma. No specific conclusions can be drawn from our comparative study, but inferences can be made. The uncorrected survival statistics in both groups seem to be identical-48 per cent in the coagulation group and 46 per cent in the abdominoperineal resection group. Whether electrocoagulation stimulates an antibody response as described by Strauss [2] remains a moot point. Studies are now in progress to determine whether this is so. We strongly believe that large numbers of patients need not undergo abdominoperineal resection in order to receive the maximum benefit of medical care for the treatment of carcinoma of the rectum.
Volume 132, November 1876
585
Salvati
and Rubin
Summary
The survival of forty-seven patients with cancer of the rectum treated by electrocoagulation is compared with thirty-seven patients treated by abdominoperineal resection. The one to ten year survival for the electrocoagulation group was 48 per cent and the one to eight year survival for the abdominoperineal resection group was 46 per cent. We believe that electrocoagulation when selectively applied has a place in the management of cancer of the rectum. References 1. Wassink WF: The curative treatment of carcinoma recti by means of electrocoagulation and radium. Arch Chir Neerl 8: 313, 1956. 2. Strauss A, Strauss S, Crawford R. Strauss H: Sugical dtathermy of carcinoma of the rectum. JAMA 104: 1460. 1935. 3. Ferguson LK: Treatment of carcinoma of the rectum and rectosigmoid by electrocoagulation. New lnt C/in 1: 199, 1940.
588
4. Kergin FG: Diathermy fulguration in the treatment of certain cases of rectal carcinoma. Can Med Assoc J 69: 14, 1953. Klok PAA: The treatment of some forms of rectal cancer by electrocoagulation. Arch C/in Neerll6: 173, 1964. Madden JL. Kandalaft S: Electrocoagulation in the treatment of cancer of the rectum. Ann Surg 174: 530, 197 1. Swerdlow DB, Salvati EP: Electrocoagulation of cancer of the rectum. Dis Colon Rectum 15: 228, 1972. Crile G, Turnbull RB: The role of electrocoagulation in the treatment of carcinoma of the rectum. Surg Gm/ obsfef 135: 391.1972. 9. Phillips DL. Edmond JA: Fulguration as primary treatment of cancer of the rectum. Maine h&d Assoc 62: 236, 1971. 10. Poirier A, Poirier B: Sur I’electrocoagulation dans Ia cancer du rectum. Gaz MedFrance 62:1525, 1955. 11. Jackman RJ: Conservative management of selected patients with carcinoma of the rectum. Dis Colon Rectum 4: 429, 1961. 12. Bordos DC, Baker RR. Cameron JL: An evaluation of palliative abdominoperineal resection for carcinoma of the rectum. Surg Gynecol Obstet 139: 73 1, 1974. 13. Gilbertsen VA: The results of the surgical treatment of cancer of the rectum. Surg Gynecol Obstet 114: 313, 1962. 14. Dukes C: Histological grading of rectal cancer. Rot R See Med 30: 371, 1937.
lho Amafkm
Journal 04 Surfpry
