253
Aust. N . Z . J . Surg. 1990, 60, 253-259
ORIGINAL ARTICLES MORBIDITY, MORTALITY AND SURVIVAL FOLLOWING RESECTION FOR CARCINOMA OF THE RECTUM AT CONCORD HOSPITAL E. L. BOKEY,P. H. CHAPUIS, W. J. HUGHES,S . G. KOOREY,J . M. HINDER AND R. EDWARDS University of Sydney, Department of Colon and Rectal Surgery, Concord Hospital, Concord, New South Wales Colorectal cancer is the most common internal malignancy in Australia, and the rectum is the most common site. The morbidity, mortality and survival of 561 consecutive patients with rectal cancer who had a resection at Concord Hospital during the 16-year period 1971-86 were evaluated. More than half of the operations performed were low anterior resections (LAR), with total abdominoperineal excisions (APE) of the rectum comprising another third. There was a 5.1% mortality rate in LAR patients and a 3.1YOmortality rate in the APE group. Respiratory complications, urinary tract infections and wound infections were the most common causes of morbidity in both LAR and APE. The median survival for patients treated by LAR and APE standardized for clinicopathological staging was 1 1 1.5 and 47.1 months (A), 79.0 and 65.5 months (Bj, 41.3 and 28.5 (C), and 14.7 and 12.4 (Dj. respectively.
Key words: abdominoperineal excision, Australia, cancer, clinicopathological staging, colorectal cancer, low anterior resection.
Introduction Colorectal cancer (CRC) is the most common internal malignancy in Australia and the rectum is the most common site. The aim of this paper is to review the morbidity, mortality and survival of 561 consecutive patients with rectal cancer who had a resection at Concord Hospital during the period 1971-86. All data were collected prospectively and stored on computer file. Less than 5 % of patients were lost to follow-up to the end of June 1987.
Methods Between 1971 and 1986, prospective data on all patients admitted to Concord Hospital who had either a potentially curative or a palliative resection of the rectum for carcinoma were collated, coded and stored on computer file at the University of Sydney. Retrieval of the data, statistical and survival analyses were all performed using a standard statistical package. In 516 patients, the rectum, including the recto-
'
Correspondence: Assoc. Prof. E. L. Bokey, University of Sydney, Department of Colon and Rectal Surgery, Clinical Sciences Building, Repatriation General Hospital. Concord, NSW 2139, Australia. Accepted for publication 15 November 1989.
sigmoid junction, was defined pre-operatively by rigid sigmoidoscopy as within 18 cm from the anal verge or at or below the sacral promontory at operation. Pre-operative biopsy confirmation of carcinoma was obtained in all patients. Whenever possible, synchronous proximal tumours were excluded either by colonoscopy or by double contrast barium enema. Apart from a routine chest X-ray, patients clinically suspected of having distant spread, and those with abnormal liver function tests were assessed further for liver metastases, either by isotope liver scintography or by an abdominopelvic computerized scan. All patients suspected of having a bulky or relatively fixed tumour were examined under anaesthesia. Cystoscopy was performed if bladder involvement was suspected, or in selected cases for ureteric catheterization, to assist the surgeon in identifying the ureters at operation. In January 1979, a standard method of bowel preparation, draping and surgical technique was adopted by all members of the Colon and Rectal Unit. In the absence of clinical obstruction, an orthograde mechanical bowel preparation was used and antimicrobial prophylaxis using metronidazole and gentamicin was administered at induction of anaesthesia, and repeated eight h after operation. Subcutaneous heparin, TED stockings and pulsed calf stimulation were used for thromboembolic prophylaxis. All patients were operated on through a long
BOKEY ET AL.
254
mid-line abdominal incision. A low anterior resection (LAR) was defined as a restorative operation in which the extraperitoneal rectum was mobilized sufficiently to enable adequate distal clearance of the tumour, and construction of a tension-free anastomosis below the peritoneal reflection. The splenic flexure was fully mobilized in all patients who had an LAR. In these patients, the inferior mesenteric vessels were ligated and divided, usually below the origin of the ascending left colic artery. Colorectal anastomoses were performed either by an interrupted, single layer technique or by a stapling device. In all patients suitable for a restorative operation, the rectal stump was irrigated thoroughly with water prior to division. In 8 1 % of patients who had an LAR, the margin of distal clearance was equal to or greater than 2cm from the inferior edge of the tumour measured in the fresh state. In 19% of patients, the distal margin was 1-2cm wide. The proximal line of transection of the colon depended on the presence of an adequate arterial pulsatile flow which was tested for routinely by dividing the marginal artery prior to its ligation, and on the absence of muscle hypertrophy or diverticula. In all patients, two sump drains were positioned in the presacral space for suction and irrigation using normal saline. These were usually removed within 48 h of operation. Anastomotic leaks were defined as ‘general’ if there was evidence of spreading peritonitis, or ‘localized’ if the process was confined to the pelvis and resolved spontaneously without further abdominal surgery. Since 1979, a standard method of performing an abdominoperineal excision of the rectum (APE) has been adopted. The hypogastric plexus was identified and preserved, and the presacral space developed by sharp dissection. The rectum was fully mobilized by the abdominal operator down to the levator ani, and the dissection completed synchronously by the perineal operator using diathermy, after infiltration of the skin with a 1 : 30 solution of POR-8. The paracolostomy space was closed, the stoma exteriorized, and the perineal wound approximated around a corrugated drain. In 18% of patients, the wound was packed and left open. In this series, 92% of all specimens were examined in the fresh state and over 90% of the tumours were graded and staged by one pathologist. Tumours were staged using a clinicopathological (CP) system, developed at Concord Hospital.’ All patients were followed up postoperatively every 3 months in the first year and yearly thereafter. Local recurrence (LR) was defined as a histologically proven recurrence occurring at or near the primary tumour site in the absence of distant metastases in a live patient, with a minimal follow-up of 2 years.
Results Between January 1971 and December 1986, 561 consecutive patients with a histological diagnosis of adenocarcinoma of the rectum had a resection at Concord Hospital. The mean duration of symptoms prior to diagnosis was 26.3 weeks. There were 442 men (mean age = 67’1 years’ s.d’ = 9’5) and 139 (mean age = 68 years’ s‘d’ = 12’2)and the age range was 21-90 years. Tumour distance measured from the anal verge is shown in Fig. 1. On digital examination, the tumour was palpable in 323 patients (57.6%) and was visualized through a proctoscope in 98 patients.
Fig. 1. Tumour location within the rectum according to distance measured from anal verge.
Four patients had a past history of inflammatory bowel disease, of whom three had ulcerative colitis and one had Crohn’s disease. Seventeen patients had had a previous polypectomy for benign adenoma, and 12 patients had had a previous resection for CRC. Thirty-eight patients had a family history of CRC, and one patient belonged to a polyposis coli family. Table 1 summarizes the tumour stages and Table 2 highlights the more important pathological features of the resected specimens. The operations performed are shown in Table 3. Twenty patients (3.6%) had an urgent operation, either for obstruction in 16 patients, or tumour perforation in four patients. Three hundred and fourteen patients had an LAR and 189 patients had an APE of the rectum. Figure 2 illustrates the pattern of surgical treatment (LAR versus APE) for the study period. The rise in the proportion of patients who had an LAR was statisti-
255
RESECTION FOR RECTAL CARCINOMA
Table 1. Stage distribution of 561 rectal cancers C P stage
No.
Yo
A B C D”
89 181 187 104
15.8 32.3 33.3 18.5
*Incurable.
Table 2. Pathology of resectecd specimens (n = 561) Description
No.
Yo
Lymph node involvement Venous invasion High grade turnours Divenicular disease Mucinous tumours Contiguous adenoma Synchronous primaries Invasion of adjacent viscus
26 1 158 139 45 39 38 24 15
46.5 28.1 24.7 8.0 7.0 6.8 4.3 2.7
Table 3. Operations performed, 1971-86 (n = 561) Operation
cally significant. Table 4 compares the proportion of LAR performed according to the pre-operative level of the tumour for the periods 1971-78 and 1979-86 inclusive. Of patients who had an LAR, 26% had an associated (synchronous) colostomy. The postoperative, in-hospital mortality rate for 503 patients who had either an LAR or an APE was 4.3%. The most frequent cause of death was cardiovascular complications. Three patients died following anastomotic leakage (Table 5). Table 4. Operation performed by level of tumour measured from anal verge and year of operation (n = 503) Tumorlevel No. (cd APE
1971-78 No. Yo LAR LAR
No. APE
1979-86 No. % LAR LAR
(7 7-12 > 12
42 55 8
1 40 42
2.3 42.1 84
64 16 4
25 138 68
28.1 89.6 94.5
Total
105
83
44.1
84
231
73.4
%
No.
Table 5. Hospital mortality by operation type Restorative Anterior resection High Low Pull-through Coloanal anastomosis
16 314 1 12
2.8 56.0
189
34.0 0.9
Excisional Total (APE) Proctocolectom y
2.1
5
Other Hartmann’s Unclassified
21 3
3.7
I
1971
1974
1977
1980
1983
1986
Year
Fig. 2. Type of surgery performed for rectal cancer showing a progressive increase in the use of LAR. For LAR, I’ = 0.7512, P = 0.0008; for APE, r = -0.9071, P < 0.0001.
Cause of death Cardiovascular Anastomotic leak Respiratory Thrombo-enibolic Septicaemia Other Total
LAR
APE
( n = 314)
(n = 189) NO. Yo
NO.
740
6 3 2 2 I 2 16
5.1
6
3.1
Eight patients developed a significant clinical leak ( 2 . 5 % ) , 30 patients developed a local leak (9.5%) and 10 patients had a faecal fistula (3.2%) after LAR. Table 6 summarizes the prevalence of anastomotic complications for the 15 year period in 5-year groups from 1971 to 1985 inclusive. The fall in incidence of ‘local’ leaks (13.9%) occurring in the period 1971-75 to 7.7% for the period 198185 was not significant. Large tumours (> 6 c m in diameter) were associated with a higher incidence of ‘general’ leaks and faecal fistulae (P= 0.04; Table 7). The incidence of anastomotic leaks was not significantly greater in elderly patients more than 70 years of age, nor was it affected by advancing tumour stage (Table 8). Anastomotic complications were not related to the distance of the tumour from the anal verge (Table 9), or to the anastomotic technique (Table 10).
256
BOKEY ET AL.
Table 6. Anastoinotic leaks following LAR for 1971-85"
Table 10. Anastomotic technique and anastornotic coniplications in 3 14 patients after LAR
Anastomotic leak LAR Period
I?
1971-75 1976-80 1981-85
36 103 143
Local General No. '% No. YO
Faecal fistula No. % Technique
'ii
5 9 II
13.9 8.7 7.7
-
2 4
1.9 2.8
5.6 3.9 1.4
2 4 2
IZ
Anastomotic complication Local General Faecal leak leak fistula No. YO No. % No. YO
I layer 2 layer Staple
85 67 162
5 6 19
Total
314
30
59 9 11.7
3 I 4
3.5 1.5 2.5
2 6 2
2.4 9 1.2
1.AR = 2x2
8
10
Table 7. Anastoinotic leak following LAR by tumour
Anastoniotic leak
< 6cm
Local No. % General No.
(TI
Tuniour size 257) > 6 c m
=
23 9
0 %
Faecal fistula NO. %
=
(11
57)
7 12.3
3 4: I .2
5 8.8
5 :% 1.9
5 8.8
"Fisher's exact test
Table 8. Anastomotic leak following LAR by age and tuniour stage":
Variable
Anastomotic leak No. Yo
I7
Age (years) < 69 > 70 Stage A B C
D
I77 I37
21 27
12 19.7
55 96 112 51
4 16 18 8
7.3 16.6 16. I 15.7
Other postoperative complications are listed in Table 11. Table 12 shows a statistically significant fall in the incidence of wound infection after APE from 36.2% for the first 5-year period to 1975, to 13.5% in the last 5-year period, 1981-85 ( P = 0.008). The incidence of cardiac complications was significantly greater only for patients who had an LAR and who were aged 3 70 years ( P = 0.007; Table 13). The incidence of LR alone in 457 patients who had a potentially curative operation was 7.2%. Thirty-eight patients (8.3%) developed an LR in the pelvis in the presence of distant metastases. The incidence of LR alone was not significantly different between 260 patients who had a curative LAR (9.2%) and 148 patients who had a curative APE (4.7%). Only patients who had a stage C tumour treated by APE had a significantly diminished survival compared with those who had an LAR (Table 14).
Table 11. Postoperative morbidity by operation type
(17
Table 9. Anastomatic complication and level of tumour from anal verge in 314 patients after LAR Tuniour level (cm)
ii
26 178
Anastomatic complication Local General Faecal leak leak fistula Yo NO. '/o NO. NO.
(7 7-12 > 12
110
I 21 8
Total
314
30
3.8 11.8 7.2
2 2 4 8
7.6 11.2 3.6
2 4 4 10
7.6 2.2 3.6
Operation LAR APE = 314) ( n = 189)
Morbidity
NO.
Wound infection Wound dehiscence Urinary tract infection Urinary retention (acute) Urinary incontinence Respiratory Cardiac Deep vein thrombosis Embolism Prolonged perineal sinus (> 6 weeks)
34 5 35 4 2 54 20 8 II
_
NO.
3' 0'
1.3 0.6 17.2 6.4 2.5 3.5
42 7 24 10 6 26 9 6 3
22.2 3.7 12.7 5.3 3.2 13.8 4.8 3.2 1.6
-
23
12.2
Yo
10.8 1.6 11.1
RESECTION FOR RECTAL CARClNOMA
257
Table 12. Postoperative wound infection by operation type according to year of operation ( I 97 1-85)
Operative period
12
LAR NO.
1971-75 1876-80 1981-85
36 103 143
5 12 13
APE u/'
13.9 11.7 9.1
n
No.
69 60 52
25 10 7
OO /
36.2'x 16.7 13.5"
Fisher's exact test.
Table 13. Postoperative cardiorespiratory complications by age and operation type
Respiratory No. %
NO.
Yo
177 137
24 30
13.5 21.9
5" 15*'
2.8 10.9
109 80
14 12
12.8 15.0
4 5
3.6 6.2
17
Cardiac
LAR
Age (years)
< 69
> 70 APE Age (years) (69 > 70
"Fisher's exact test.
Table 14. Pairwise comparison of differences in survival for patients treated by LAR and APE standardized for CP
stage Median survival
(months) APE
CP stage
LAR
A B
111.5 79.0
C
41.3 14.7
D
47.1 65.5 28.5 12.4
Pairwise comparison" P 3.6 0.07 7.4 0.7
0.06 0.80 0.006 0.39
.'Using Lee-Desu statistic for I df
Discussion Rectal cancer is a common tumour and its incidence is increasing in our ageing p ~ p u l a t i o n .Although ~ there are numerous reports from other countries detailing the complications associated with rectal excision for ~ a n c e r there ,~ are relatively few from Au~tralia.~.'We therefore thought it would be instructive to review our experience with this tumour. The overall hospital mortality for this series was low (4.3%), and most postoperative deaths were related to cardiorespiratory complications. The mortality was not significantly higher in patients older than 70 years, although there was a higher incidence of cardiac complications following LAR in that age group. Therefore surgery is recommend-
ed even in elderly patients, provided that careful pre- and postoperative attention is given to achieving optimal cardiorespiratory function. Anastomotic leakage following LAR is a serious complication, and if the incidence were high it would deter us from recommending a restorative procedure. We have classified anastomotic leakage according to its clinical significance. Anastomotic leakage causing peritonitis and necessitating reoperation is different from that causing a localized abscess which drains spontaneously without further abdominal surgery. According to these criteria, the incidence of clinically significant leakage in this series was low (2.5%); furthermore, the incidence was not related to the distance of the tumour from the anal verge. Unlike other reports, it was not found that low tumours treated by restorative operation have a higher incidence of anastomotic In this audit, the leak rate was also unrelated to the method of anastomosis or to the age of the patient, and, although patients with a stage A tumour had a lower anastomotic leak rate, this did not reach statistical significance. There was, however, a higher incidence of anastomotic complications in large tumours (> 6cm). Based on these findings, a restorative procedure is reconmended, provided that adequate surgical clearance of the cancer can be achieved and also that the patient's pre-operative continence is adequate. However, caution is advised before undertaking LAR in patients with large bulky tumours. Several studies have suggested that stapled anastomoses are more secure than hand-sewn ones; however, the majority of these reports is based on uncontrolled studies, so that no statistically significant conclusions can be drawn from the data presented.'" The results in the present series suggest that there is no real advantage of stapled anastomoses over a hand-sutured technique, and our initial assessment of circular staplers previously reported remains unchanged. I ' Provided that the blood supply is adequate and there is no tension on the anastomosis, it is improbable that anastomotic leakage is related to the actual method of anastomosis. Furthermore, although the incidence of anastomotic complications in this series was lower in the latter part of the study, this did not reach statistical significance. This trend may equally be attributed to the adoption by all members of the Unit of a standard technique, whereby the splenic flexure and rectum are fully mobilized to ensure no tension on the anastomosis. It is believed that a meticulous attention to blood supply, especially of the proximal segment, is important in achieving a satisfactory result. In this study, almost 10% of the patients had associated diverticular disease. We have previously reported a higher incidence of complications
258
associated with bowel resection in patients with diverticular disease than in those with carcinoma. I * In view of this, in patients with both diverticular disease and carcinoma, it should be ensured that the proximal line of resection is clear of bowel affected by hypertrophied muscle and a narrowed lumen. This, at times, has entailed resecting most of the descending colon, and sometimes the distal part of the transverse colon, and relying on the middle colic artery for adequate blood supply. Both colonic and rectal ends are then prepared for anastomosis by clearing all fat for at least 1 cm from the bowel ends. This ensures that an adequate portion of muscle is clearly visualized and safely included in the anastomosis. The decreasing incidence of wound infection over the study period coincides with the introduction of anti-anaerobic prophylaxis. The incidence of wound infection in the latter part of the study remains disappointingly high (LAR 9.1YO;APE l 3 S o / o ) . A high incidence of urinary tract complications including bladder dysfunction has been reported previously, and it was shown that these complications occur more frequently with low, locally advanced rectal turnours. I 3 , l 4 The symptoms of LR may be very distressing, especially after LAR. The discrepancy in the wide variation in the reported incidence of this serious complication is multifactorial and also partly related to definition. In this series using our criteria, the incidence of LR was 7.2% and was not significantly different whether following LAR and APE. It has been shown previously that the incidence is higher following LAR in patients with lymph node metastases. I 6 There have been reports suggesting that LR is more common following a stapled anastomosis," yet we have previously shown that the anastoinotic method itself does not influence the development of LR, and that involvement of regional lymph nodes is the more important factor in the development of LR. I' Unfortunately, there is currently no accurate method of detecting preoperatively lymph node involvement, although transrectal ultrasonography is promising. I' In this series, survival following excision for rectal cancer was dependent on the stage of the tumour and was the same following LAR and APE. It has not been possible to explain why patients with a stage C tumour who had an APE had a significantly diminished survival compared with those who had an LAR, although this finding agrees with other reports.*',*' These results suggest that a restorative procedure for rectal cancer is the preferred method of treatment and is not associated with a significantly higher morbidity or mortality. Advanced age per se is not a contra-indication to surgery; however, careful pre-operative assessment is necessary to
BOKEY ET A L .
minimize postoperative cardiac complications, especially following LAR. Patients with a large bulky tumour are at greater risk of anastomotic complications and, in this group, we tend to avoid a restorative procedure. Patients with a stage C tumour present a dilemma in that, although survival is better following LAR, the incidence of LR is higher than after APE. Currently, there is no proven reliable method of identifying these patients pre-operatively .
Acknowledgements The authors gratefully acknowledge Wynn McGufficke and Eric Smyth for their invaluable assistance in the collation, coding and computer analysis of the data.
References PACKAGE I:OK 'THE STATISTICAL SCIENCES Inc. I . SOFTWARE (1988) SPSS-X user'.^ Guide. 3rd edn. SPSS lnc., Chicago. R. C., CHAPUIS P. H. & SMYrH E. J . (1987) 2. NEWLAND The prognostic value of substaging colorectal carcinoma: A prospective study of 11 17 cases with standardised pathology. Cancer 60, 852-7. L., CIIAIV.JIS P. H. & GOUL3. Dkivr 0. F., MACDONALL) STON K. (1981) Colorectal cancer in Australia, 19081978. Med. J . Aust., 2, 415-6. 4. K Y L L O NL.~ N E. J . & HUSAA. I. (1986) Carcinoma of the rectum in Finland - Changes in two decades: an epidemiologic and clinical study. Actci Chir. Scund. 152, 749-62. D. E . , COHENJ. R . , HoLr J . & DAVISN . C. 5 . THEILE (1979) Mortality and complications of large bowel resection for carcinoma. Aust. N.Z.J . Surg. 49, 62-6. 6. HUGHES E. S . R., McDERMoi-r F. T., MASTERTON J . P., CUNNINGHAM I. G . E. & POLGLASE A. L. ( I 980) Operative mortality following excision of the rectum. 5 r i / . J . Surg. 67, 49-51, 0. E. & K ~ L LKY. A. (1980) Anterior resec7. AKWARI tion for adenocarcinoma of the distal large bowel. Arner. J . Surg. 139. 88-94. L. P., STtWAiI.I.-BKOWN s., BLESOVSKY 1. & 8. FIELDING G. (1980) Anastomotic integrity after operaKAKNEY tions for large bowel cancer: A nullticentre study. Brit. Med. J . 281, 411-4. J . C., GRAHAM N . G. & DE DOMBAL F. T. 9. GOLIGHER ( 1970) Anastomotic dehiscence after anterior resection of' rectum and sigmoid. Brit. J . Surg. 57, 109- 18. B. P. (1983) Large bowel anastonloses 1 1 . 10. WAXMAN The circular staplers. Brit. J . Surg. 70, 64-7. M. T . , HUGHES W . J . , KOOREY 1 1 . BOKEYE. L., PHEILS S . G. & CHAPUIS P. H. (1982). Anterior resection for carcinoma of the rectum: The use of the EEA stapling device. Colopi-octology4, 265-8. E. L., CHAPUIS P. H. & PtiEiLs M. T. (1981) 12. BOKEY Elective resection for diverticular disease and carci-
noma. Coinparison of postoperative morbidity and mortality. Dis. Col. Rect. 24, 181-2.
RESECTION FOR RECTAL CARCINOMA
13. WATTERS G. R., BOKEYE. L., CHAPUIS P. H., MAHER P. W. & PHEILSM. T. (1983) Urological complications following ahdominoperineal excision of the rectum for carcinoma. Aust. N.Z. J . Surg. 53, 445-7. 14. JANUN. C., BOKEYE. L., CHAPUIS P. H., WAITERS G. R., MAHER P. 0. & ANGSTREICH D. (1986) Bladder dysfunction following anterior resection for carcinoma of the rectum. Dis.Col. Rect. 29, 182-3. 15. KEIGHLEY M. R. B. & HALLC. (1987) Anastomotic recurrence of colorectal cancer - a histological phenomenon or an avoidable calamity? Gut 28, 786-91. 16. PHEILSM. T., CHAPUIS P. H . , NEWLAND R. C. & COLQUHOUN K. (1983) Local recurrence following curative resection for carcinoma of the rectum. Dis. Col. Rect. 26, 98-102. 17. HURST P. A,, PROUT W. G., KEELY J . M., BANNISTER J. J. & WALKER R. T . (1982) Local recurrence after
259
18.
19.
20.
21.
low anterior resection using the staple gun. Brir. J . Surg. 69, 275-6. BOKEY E. L., CHAPUIS P. H . , HUGHES W. J . , KOOREY S . G. & DUNND. (1984) Local recurrence following anterior resection for carcinoma of the rectum with a stapled abastomosis. Acta Chir. Scand. 150, 683-6, BEYNON J. (1989) An evaluation of the role of rectal endosonography in rectal cancer. Ann. R. Coll. Surg. Engl. 71, 131-9. P A m S . , TOVEE E. B. & LANCER B. (1977) Twentyfive years of experience with radical surgical treatment of carcinoma of the extraperitoneal rectum. Surgery 82, 460-5. NICHOLLS R. J . , RITCHIEJ . K . , WADSWORTH J. & PARKSA. G. C. (1979) Total excision or restorative resection for carcinoma of the middle third of the rectum. Brit. J . Surg. 66, 625-7.
Aust. N . Z . J . Surg. 1990, 60, 253-259
ORIGINAL ARTICLES MORBIDITY, MORTALITY AND SURVIVAL FOLLOWING RESECTION FOR CARCINOMA OF THE RECTUM AT CONCORD HOSPITAL E. L. BOKEY,P. H. CHAPUIS, W. J. HUGHES,S . G. KOOREY,J . M. HINDER AND R. EDWARDS University of Sydney, Department of Colon and Rectal Surgery, Concord Hospital, Concord, New South Wales Colorectal cancer is the most common internal malignancy in Australia, and the rectum is the most common site. The morbidity, mortality and survival of 561 consecutive patients with rectal cancer who had a resection at Concord Hospital during the 16-year period 1971-86 were evaluated. More than half of the operations performed were low anterior resections (LAR), with total abdominoperineal excisions (APE) of the rectum comprising another third. There was a 5.1% mortality rate in LAR patients and a 3.1YOmortality rate in the APE group. Respiratory complications, urinary tract infections and wound infections were the most common causes of morbidity in both LAR and APE. The median survival for patients treated by LAR and APE standardized for clinicopathological staging was 1 1 1.5 and 47.1 months (A), 79.0 and 65.5 months (Bj, 41.3 and 28.5 (C), and 14.7 and 12.4 (Dj. respectively.
Key words: abdominoperineal excision, Australia, cancer, clinicopathological staging, colorectal cancer, low anterior resection.
Introduction Colorectal cancer (CRC) is the most common internal malignancy in Australia and the rectum is the most common site. The aim of this paper is to review the morbidity, mortality and survival of 561 consecutive patients with rectal cancer who had a resection at Concord Hospital during the period 1971-86. All data were collected prospectively and stored on computer file. Less than 5 % of patients were lost to follow-up to the end of June 1987.
Methods Between 1971 and 1986, prospective data on all patients admitted to Concord Hospital who had either a potentially curative or a palliative resection of the rectum for carcinoma were collated, coded and stored on computer file at the University of Sydney. Retrieval of the data, statistical and survival analyses were all performed using a standard statistical package. In 516 patients, the rectum, including the recto-
'
Correspondence: Assoc. Prof. E. L. Bokey, University of Sydney, Department of Colon and Rectal Surgery, Clinical Sciences Building, Repatriation General Hospital. Concord, NSW 2139, Australia. Accepted for publication 15 November 1989.
sigmoid junction, was defined pre-operatively by rigid sigmoidoscopy as within 18 cm from the anal verge or at or below the sacral promontory at operation. Pre-operative biopsy confirmation of carcinoma was obtained in all patients. Whenever possible, synchronous proximal tumours were excluded either by colonoscopy or by double contrast barium enema. Apart from a routine chest X-ray, patients clinically suspected of having distant spread, and those with abnormal liver function tests were assessed further for liver metastases, either by isotope liver scintography or by an abdominopelvic computerized scan. All patients suspected of having a bulky or relatively fixed tumour were examined under anaesthesia. Cystoscopy was performed if bladder involvement was suspected, or in selected cases for ureteric catheterization, to assist the surgeon in identifying the ureters at operation. In January 1979, a standard method of bowel preparation, draping and surgical technique was adopted by all members of the Colon and Rectal Unit. In the absence of clinical obstruction, an orthograde mechanical bowel preparation was used and antimicrobial prophylaxis using metronidazole and gentamicin was administered at induction of anaesthesia, and repeated eight h after operation. Subcutaneous heparin, TED stockings and pulsed calf stimulation were used for thromboembolic prophylaxis. All patients were operated on through a long
BOKEY ET AL.
254
mid-line abdominal incision. A low anterior resection (LAR) was defined as a restorative operation in which the extraperitoneal rectum was mobilized sufficiently to enable adequate distal clearance of the tumour, and construction of a tension-free anastomosis below the peritoneal reflection. The splenic flexure was fully mobilized in all patients who had an LAR. In these patients, the inferior mesenteric vessels were ligated and divided, usually below the origin of the ascending left colic artery. Colorectal anastomoses were performed either by an interrupted, single layer technique or by a stapling device. In all patients suitable for a restorative operation, the rectal stump was irrigated thoroughly with water prior to division. In 8 1 % of patients who had an LAR, the margin of distal clearance was equal to or greater than 2cm from the inferior edge of the tumour measured in the fresh state. In 19% of patients, the distal margin was 1-2cm wide. The proximal line of transection of the colon depended on the presence of an adequate arterial pulsatile flow which was tested for routinely by dividing the marginal artery prior to its ligation, and on the absence of muscle hypertrophy or diverticula. In all patients, two sump drains were positioned in the presacral space for suction and irrigation using normal saline. These were usually removed within 48 h of operation. Anastomotic leaks were defined as ‘general’ if there was evidence of spreading peritonitis, or ‘localized’ if the process was confined to the pelvis and resolved spontaneously without further abdominal surgery. Since 1979, a standard method of performing an abdominoperineal excision of the rectum (APE) has been adopted. The hypogastric plexus was identified and preserved, and the presacral space developed by sharp dissection. The rectum was fully mobilized by the abdominal operator down to the levator ani, and the dissection completed synchronously by the perineal operator using diathermy, after infiltration of the skin with a 1 : 30 solution of POR-8. The paracolostomy space was closed, the stoma exteriorized, and the perineal wound approximated around a corrugated drain. In 18% of patients, the wound was packed and left open. In this series, 92% of all specimens were examined in the fresh state and over 90% of the tumours were graded and staged by one pathologist. Tumours were staged using a clinicopathological (CP) system, developed at Concord Hospital.’ All patients were followed up postoperatively every 3 months in the first year and yearly thereafter. Local recurrence (LR) was defined as a histologically proven recurrence occurring at or near the primary tumour site in the absence of distant metastases in a live patient, with a minimal follow-up of 2 years.
Results Between January 1971 and December 1986, 561 consecutive patients with a histological diagnosis of adenocarcinoma of the rectum had a resection at Concord Hospital. The mean duration of symptoms prior to diagnosis was 26.3 weeks. There were 442 men (mean age = 67’1 years’ s.d’ = 9’5) and 139 (mean age = 68 years’ s‘d’ = 12’2)and the age range was 21-90 years. Tumour distance measured from the anal verge is shown in Fig. 1. On digital examination, the tumour was palpable in 323 patients (57.6%) and was visualized through a proctoscope in 98 patients.
Fig. 1. Tumour location within the rectum according to distance measured from anal verge.
Four patients had a past history of inflammatory bowel disease, of whom three had ulcerative colitis and one had Crohn’s disease. Seventeen patients had had a previous polypectomy for benign adenoma, and 12 patients had had a previous resection for CRC. Thirty-eight patients had a family history of CRC, and one patient belonged to a polyposis coli family. Table 1 summarizes the tumour stages and Table 2 highlights the more important pathological features of the resected specimens. The operations performed are shown in Table 3. Twenty patients (3.6%) had an urgent operation, either for obstruction in 16 patients, or tumour perforation in four patients. Three hundred and fourteen patients had an LAR and 189 patients had an APE of the rectum. Figure 2 illustrates the pattern of surgical treatment (LAR versus APE) for the study period. The rise in the proportion of patients who had an LAR was statisti-
255
RESECTION FOR RECTAL CARCINOMA
Table 1. Stage distribution of 561 rectal cancers C P stage
No.
Yo
A B C D”
89 181 187 104
15.8 32.3 33.3 18.5
*Incurable.
Table 2. Pathology of resectecd specimens (n = 561) Description
No.
Yo
Lymph node involvement Venous invasion High grade turnours Divenicular disease Mucinous tumours Contiguous adenoma Synchronous primaries Invasion of adjacent viscus
26 1 158 139 45 39 38 24 15
46.5 28.1 24.7 8.0 7.0 6.8 4.3 2.7
Table 3. Operations performed, 1971-86 (n = 561) Operation
cally significant. Table 4 compares the proportion of LAR performed according to the pre-operative level of the tumour for the periods 1971-78 and 1979-86 inclusive. Of patients who had an LAR, 26% had an associated (synchronous) colostomy. The postoperative, in-hospital mortality rate for 503 patients who had either an LAR or an APE was 4.3%. The most frequent cause of death was cardiovascular complications. Three patients died following anastomotic leakage (Table 5). Table 4. Operation performed by level of tumour measured from anal verge and year of operation (n = 503) Tumorlevel No. (cd APE
1971-78 No. Yo LAR LAR
No. APE
1979-86 No. % LAR LAR
(7 7-12 > 12
42 55 8
1 40 42
2.3 42.1 84
64 16 4
25 138 68
28.1 89.6 94.5
Total
105
83
44.1
84
231
73.4
%
No.
Table 5. Hospital mortality by operation type Restorative Anterior resection High Low Pull-through Coloanal anastomosis
16 314 1 12
2.8 56.0
189
34.0 0.9
Excisional Total (APE) Proctocolectom y
2.1
5
Other Hartmann’s Unclassified
21 3
3.7
I
1971
1974
1977
1980
1983
1986
Year
Fig. 2. Type of surgery performed for rectal cancer showing a progressive increase in the use of LAR. For LAR, I’ = 0.7512, P = 0.0008; for APE, r = -0.9071, P < 0.0001.
Cause of death Cardiovascular Anastomotic leak Respiratory Thrombo-enibolic Septicaemia Other Total
LAR
APE
( n = 314)
(n = 189) NO. Yo
NO.
740
6 3 2 2 I 2 16
5.1
6
3.1
Eight patients developed a significant clinical leak ( 2 . 5 % ) , 30 patients developed a local leak (9.5%) and 10 patients had a faecal fistula (3.2%) after LAR. Table 6 summarizes the prevalence of anastomotic complications for the 15 year period in 5-year groups from 1971 to 1985 inclusive. The fall in incidence of ‘local’ leaks (13.9%) occurring in the period 1971-75 to 7.7% for the period 198185 was not significant. Large tumours (> 6 c m in diameter) were associated with a higher incidence of ‘general’ leaks and faecal fistulae (P= 0.04; Table 7). The incidence of anastomotic leaks was not significantly greater in elderly patients more than 70 years of age, nor was it affected by advancing tumour stage (Table 8). Anastomotic complications were not related to the distance of the tumour from the anal verge (Table 9), or to the anastomotic technique (Table 10).
256
BOKEY ET AL.
Table 6. Anastoinotic leaks following LAR for 1971-85"
Table 10. Anastomotic technique and anastornotic coniplications in 3 14 patients after LAR
Anastomotic leak LAR Period
I?
1971-75 1976-80 1981-85
36 103 143
Local General No. '% No. YO
Faecal fistula No. % Technique
'ii
5 9 II
13.9 8.7 7.7
-
2 4
1.9 2.8
5.6 3.9 1.4
2 4 2
IZ
Anastomotic complication Local General Faecal leak leak fistula No. YO No. % No. YO
I layer 2 layer Staple
85 67 162
5 6 19
Total
314
30
59 9 11.7
3 I 4
3.5 1.5 2.5
2 6 2
2.4 9 1.2
1.AR = 2x2
8
10
Table 7. Anastoinotic leak following LAR by tumour
Anastoniotic leak
< 6cm
Local No. % General No.
(TI
Tuniour size 257) > 6 c m
=
23 9
0 %
Faecal fistula NO. %
=
(11
57)
7 12.3
3 4: I .2
5 8.8
5 :% 1.9
5 8.8
"Fisher's exact test
Table 8. Anastomotic leak following LAR by age and tuniour stage":
Variable
Anastomotic leak No. Yo
I7
Age (years) < 69 > 70 Stage A B C
D
I77 I37
21 27
12 19.7
55 96 112 51
4 16 18 8
7.3 16.6 16. I 15.7
Other postoperative complications are listed in Table 11. Table 12 shows a statistically significant fall in the incidence of wound infection after APE from 36.2% for the first 5-year period to 1975, to 13.5% in the last 5-year period, 1981-85 ( P = 0.008). The incidence of cardiac complications was significantly greater only for patients who had an LAR and who were aged 3 70 years ( P = 0.007; Table 13). The incidence of LR alone in 457 patients who had a potentially curative operation was 7.2%. Thirty-eight patients (8.3%) developed an LR in the pelvis in the presence of distant metastases. The incidence of LR alone was not significantly different between 260 patients who had a curative LAR (9.2%) and 148 patients who had a curative APE (4.7%). Only patients who had a stage C tumour treated by APE had a significantly diminished survival compared with those who had an LAR (Table 14).
Table 11. Postoperative morbidity by operation type
(17
Table 9. Anastomatic complication and level of tumour from anal verge in 314 patients after LAR Tuniour level (cm)
ii
26 178
Anastomatic complication Local General Faecal leak leak fistula Yo NO. '/o NO. NO.
(7 7-12 > 12
110
I 21 8
Total
314
30
3.8 11.8 7.2
2 2 4 8
7.6 11.2 3.6
2 4 4 10
7.6 2.2 3.6
Operation LAR APE = 314) ( n = 189)
Morbidity
NO.
Wound infection Wound dehiscence Urinary tract infection Urinary retention (acute) Urinary incontinence Respiratory Cardiac Deep vein thrombosis Embolism Prolonged perineal sinus (> 6 weeks)
34 5 35 4 2 54 20 8 II
_
NO.
3' 0'
1.3 0.6 17.2 6.4 2.5 3.5
42 7 24 10 6 26 9 6 3
22.2 3.7 12.7 5.3 3.2 13.8 4.8 3.2 1.6
-
23
12.2
Yo
10.8 1.6 11.1
RESECTION FOR RECTAL CARClNOMA
257
Table 12. Postoperative wound infection by operation type according to year of operation ( I 97 1-85)
Operative period
12
LAR NO.
1971-75 1876-80 1981-85
36 103 143
5 12 13
APE u/'
13.9 11.7 9.1
n
No.
69 60 52
25 10 7
OO /
36.2'x 16.7 13.5"
Fisher's exact test.
Table 13. Postoperative cardiorespiratory complications by age and operation type
Respiratory No. %
NO.
Yo
177 137
24 30
13.5 21.9
5" 15*'
2.8 10.9
109 80
14 12
12.8 15.0
4 5
3.6 6.2
17
Cardiac
LAR
Age (years)
< 69
> 70 APE Age (years) (69 > 70
"Fisher's exact test.
Table 14. Pairwise comparison of differences in survival for patients treated by LAR and APE standardized for CP
stage Median survival
(months) APE
CP stage
LAR
A B
111.5 79.0
C
41.3 14.7
D
47.1 65.5 28.5 12.4
Pairwise comparison" P 3.6 0.07 7.4 0.7
0.06 0.80 0.006 0.39
.'Using Lee-Desu statistic for I df
Discussion Rectal cancer is a common tumour and its incidence is increasing in our ageing p ~ p u l a t i o n .Although ~ there are numerous reports from other countries detailing the complications associated with rectal excision for ~ a n c e r there ,~ are relatively few from Au~tralia.~.'We therefore thought it would be instructive to review our experience with this tumour. The overall hospital mortality for this series was low (4.3%), and most postoperative deaths were related to cardiorespiratory complications. The mortality was not significantly higher in patients older than 70 years, although there was a higher incidence of cardiac complications following LAR in that age group. Therefore surgery is recommend-
ed even in elderly patients, provided that careful pre- and postoperative attention is given to achieving optimal cardiorespiratory function. Anastomotic leakage following LAR is a serious complication, and if the incidence were high it would deter us from recommending a restorative procedure. We have classified anastomotic leakage according to its clinical significance. Anastomotic leakage causing peritonitis and necessitating reoperation is different from that causing a localized abscess which drains spontaneously without further abdominal surgery. According to these criteria, the incidence of clinically significant leakage in this series was low (2.5%); furthermore, the incidence was not related to the distance of the tumour from the anal verge. Unlike other reports, it was not found that low tumours treated by restorative operation have a higher incidence of anastomotic In this audit, the leak rate was also unrelated to the method of anastomosis or to the age of the patient, and, although patients with a stage A tumour had a lower anastomotic leak rate, this did not reach statistical significance. There was, however, a higher incidence of anastomotic complications in large tumours (> 6cm). Based on these findings, a restorative procedure is reconmended, provided that adequate surgical clearance of the cancer can be achieved and also that the patient's pre-operative continence is adequate. However, caution is advised before undertaking LAR in patients with large bulky tumours. Several studies have suggested that stapled anastomoses are more secure than hand-sewn ones; however, the majority of these reports is based on uncontrolled studies, so that no statistically significant conclusions can be drawn from the data presented.'" The results in the present series suggest that there is no real advantage of stapled anastomoses over a hand-sutured technique, and our initial assessment of circular staplers previously reported remains unchanged. I ' Provided that the blood supply is adequate and there is no tension on the anastomosis, it is improbable that anastomotic leakage is related to the actual method of anastomosis. Furthermore, although the incidence of anastomotic complications in this series was lower in the latter part of the study, this did not reach statistical significance. This trend may equally be attributed to the adoption by all members of the Unit of a standard technique, whereby the splenic flexure and rectum are fully mobilized to ensure no tension on the anastomosis. It is believed that a meticulous attention to blood supply, especially of the proximal segment, is important in achieving a satisfactory result. In this study, almost 10% of the patients had associated diverticular disease. We have previously reported a higher incidence of complications
258
associated with bowel resection in patients with diverticular disease than in those with carcinoma. I * In view of this, in patients with both diverticular disease and carcinoma, it should be ensured that the proximal line of resection is clear of bowel affected by hypertrophied muscle and a narrowed lumen. This, at times, has entailed resecting most of the descending colon, and sometimes the distal part of the transverse colon, and relying on the middle colic artery for adequate blood supply. Both colonic and rectal ends are then prepared for anastomosis by clearing all fat for at least 1 cm from the bowel ends. This ensures that an adequate portion of muscle is clearly visualized and safely included in the anastomosis. The decreasing incidence of wound infection over the study period coincides with the introduction of anti-anaerobic prophylaxis. The incidence of wound infection in the latter part of the study remains disappointingly high (LAR 9.1YO;APE l 3 S o / o ) . A high incidence of urinary tract complications including bladder dysfunction has been reported previously, and it was shown that these complications occur more frequently with low, locally advanced rectal turnours. I 3 , l 4 The symptoms of LR may be very distressing, especially after LAR. The discrepancy in the wide variation in the reported incidence of this serious complication is multifactorial and also partly related to definition. In this series using our criteria, the incidence of LR was 7.2% and was not significantly different whether following LAR and APE. It has been shown previously that the incidence is higher following LAR in patients with lymph node metastases. I 6 There have been reports suggesting that LR is more common following a stapled anastomosis," yet we have previously shown that the anastoinotic method itself does not influence the development of LR, and that involvement of regional lymph nodes is the more important factor in the development of LR. I' Unfortunately, there is currently no accurate method of detecting preoperatively lymph node involvement, although transrectal ultrasonography is promising. I' In this series, survival following excision for rectal cancer was dependent on the stage of the tumour and was the same following LAR and APE. It has not been possible to explain why patients with a stage C tumour who had an APE had a significantly diminished survival compared with those who had an LAR, although this finding agrees with other reports.*',*' These results suggest that a restorative procedure for rectal cancer is the preferred method of treatment and is not associated with a significantly higher morbidity or mortality. Advanced age per se is not a contra-indication to surgery; however, careful pre-operative assessment is necessary to
BOKEY ET A L .
minimize postoperative cardiac complications, especially following LAR. Patients with a large bulky tumour are at greater risk of anastomotic complications and, in this group, we tend to avoid a restorative procedure. Patients with a stage C tumour present a dilemma in that, although survival is better following LAR, the incidence of LR is higher than after APE. Currently, there is no proven reliable method of identifying these patients pre-operatively .
Acknowledgements The authors gratefully acknowledge Wynn McGufficke and Eric Smyth for their invaluable assistance in the collation, coding and computer analysis of the data.
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RESECTION FOR RECTAL CARCINOMA
13. WATTERS G. R., BOKEYE. L., CHAPUIS P. H., MAHER P. W. & PHEILSM. T. (1983) Urological complications following ahdominoperineal excision of the rectum for carcinoma. Aust. N.Z. J . Surg. 53, 445-7. 14. JANUN. C., BOKEYE. L., CHAPUIS P. H., WAITERS G. R., MAHER P. 0. & ANGSTREICH D. (1986) Bladder dysfunction following anterior resection for carcinoma of the rectum. Dis.Col. Rect. 29, 182-3. 15. KEIGHLEY M. R. B. & HALLC. (1987) Anastomotic recurrence of colorectal cancer - a histological phenomenon or an avoidable calamity? Gut 28, 786-91. 16. PHEILSM. T., CHAPUIS P. H . , NEWLAND R. C. & COLQUHOUN K. (1983) Local recurrence following curative resection for carcinoma of the rectum. Dis. Col. Rect. 26, 98-102. 17. HURST P. A,, PROUT W. G., KEELY J . M., BANNISTER J. J. & WALKER R. T . (1982) Local recurrence after
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