World J. Surg. 16, 848-857, 1992
World Journal of Surgery © 1992 by the Soci~t~ lnternalionale de Chirurgie
Results of Radical Surgery for Rectal Cancer R.J. Heald, M.A., M.Chir., F . R . C . S . , F . R . C . S . ( E d . ) and N.D. Karanjia, M.S., F . R . C . S . , F . R . C . S . ( E d . ) Colorectal Research Unit, Basingstoke District Hospital, Basingstoke, England. This paper examines the hypothesis that a reduction in the distal mural margin during anterior resection for sphincter conservation in rectal cancer excision is safe, provided total mesorectal excision is undertaken with wash-out of the clamped rectum. One hundred ninety-two patients underwent anterior resection and 21 (1 cm et 42, une marge 1 cm y 42 de 1 cm (95% CI: 0.8%0-7.8%) y ninguna en el grupo - 1 cm. L a r e d u c c i r n en el margen de reseccirn, por consiguiente, no pareci6 comprometer la sobrevida despurs de una r e s e c c i r n anterior. Se discute el significado de los m ~ g e n e s laterales de r e s e c c i r n , asf como el papel de ta radioterapia profunda y de los agentes citot6xicos. Ante las bajas tasas de recurrencia local que se logran con cirugfa adecuada, es la opinirn de los autores que tales modalidades tienen poco que ofrecer en el manejo del c~ncer del recto tratado con tal tipo de cirugia radical (RTM). Finalmente, se analizan los resultados funcionales observados luego de una r e s e c c i r n anterior y RTM y se discute el problema del escape anastomrtico. References 1. Walker, A.R.P., Burkitt, D.P.: Colon cancer: Epidemiology. Semin. Oncol. 3:341, 1976 2. Office of Population Censuses and Surveys: Mortality statistics, Cause, England and Wales. Series DH2. 12:8, 1985 3. Bradpiece, H.A., Benjamin, I.S., Halevy, A.: Major hepatic resection for colorectal liver disease. Br. J. Surg. 74:324, 1987 4. Silverberg, E.: Cancer Statistics. New York, American Society, 1981 5. Heald, R.J.: Multiple primary cancers of the bowel. In Risk Factors and Multiple Cancer, B.A. Stoll, editor, Chichester, John Wiley and Sons, 1984, pp. 367-377 6. Handley, W.S.: The surgery of the lymphatic system. Br. Med. J. •:922, 1910 7. Cote, P.P.: The intramural spread of rectal carcinoma. Br. Med. J. 1:431, 1913 8. Grinnell, R.S,: Distal intramural spread of carcinoma of the rectum and rectosigmoid. Surg. Gynecol. Obstet. 99:421, 1954 9. Quer, E.A., Dahlin, D.C., Mayo, C.W.: Retrograde intramural spread of carcinoma of the rectum and rectosigmoid. Surg. Gynecol. Obstet. 96:24, 1953 t0, Williams, N.S., Dixon, M.F., Johnston, D.: Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: A study of distal intramural spread and of patients survival. Br. J. Surg. 70:!50, 1983 11. Miles, W.E.: The radical abdomino-perineal operation for cancer of the rectum and of the pelvic colon. Br. Med. J. 2:941, 1910 12. Miles, W.E.: Cancer of the rectum. London, Harrison, 1926 13. Dukes, C.E.: The spread of cancer of the rectum. Br. J. Surg. /7:643, 1930 14. Wood, W.Q., Wilkie, D.P.D.: Carcinoma of the rectum: An anatomico-pathological study. Edinb. Med. J. 40:321, 1933 15. Dukes, C.E.: Cancer of the rectum: An analysis of 1000 cases. J. Pathol. Bacteriol. 50:527, 1940 16. Goligher, J.C., Duthie, H., Nixon, H.: Surgery of the anus, rectuna and colon. London, Bailliere Tindall, 1985 17. Hojo, K., Koyama, Y., Moriya, Y.: Lymphatic spread and its
R.J. Iteald and N.D. Karanjia: Radical Surgery for Rectal Cancer prognostic value in patients with rectal cancer, Am. J, Surg. 144:350, 1982 18. Hojo, K., Koyama, Y.: The effectiveness of wide anatomical resection and radical lymphadenectomy for patients with rectal cancer. Jpn. J. Surg. 12:111, 1982 19. Hojo, K.: Postoperative follow up studies on cancer of the colon and rectum. Am. J. Surg. 143:293, 1982 20. I-Ieald, R.J., Ryall, R.D.H., Husband, E.: The mesorectum in rectal cancer surgery: Clue to pelvic recurrence. Br. J. Surg. 69:613, 1982 21. Goligher, J.C., Dukes, C.E., Bussey, H.J.R.: Local recurrences after sphincter saving excisions for carcinoma of the rectum and rectosigmoid Br J Surg. 39:199, 1951 22. Finlay, I.G., "IVlc,~rclle,C.S.: Occult hepatic metastases in colorectal carcinoma. Br. J. Surg. 73:732, 1986 23. Ridge, J.A., Daley, M.: Treatment of colorectal hepatic metastases. Surg Gynecol Obstet. •6•:597, 1985 24. Welch, j'.p., Donaldson, G.A.: The clinical correlation of an autopsy study of recurrent colorectal cancer. Ann. Surg, 189:496, 1979 25. Killingback M , Wilson, E , Hughes, E.S.R.: Anal metastases from carcinoma of the rectum and colon. Aust. N. Z. J. Surg. 34:I78, 1965 26. Lockhart-Mummery, J.p.: Resection of the rectum for cancer. Cancer I02:, 1920 27. Kraske, p.: Zur Exstirpation hochsitzender Mastdarmkrebse. Verh. Dtscht Ges. Chir. 14:464, 1885 28. Miles, W.E.: A method of performing abdomino-perineaI excision for carcinoma of the rectum and of the terminal part of the pelvic colon. Lancet 175:1812, 1908 29. Hartmann, H.: Nouveau procede d'ablation des cancers de la pattie 30. ~rminale du colon pelvien. Congr. Franc. Chir. 30:411, 1921 tJ~xon, C.F.: Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann. Surg. 128:425 1948 rucuon of 31. Goligher, J.C.: The use of stapling devices for the const " low rectal anastomoses. Ann. Chir. Gynaecol. 69:125, 1980 32. ~eading Article: Colorectal surgery: The Cinderella specialty. Br.
ed. J. 283"169, 1981 m s R T A colour 33. Lockhart-Mummery, H E , Heald, R.J., Hutch" g , . .: atlas of anterior resection of the rectum. London, Wolfe Medical Publications 1983, 64 pp 34. Karanjia N ' D , Schache, D J North, W.R.S., Heald, R.J.: The close shave in anterior reseciion Br J. Surg. 77:510, 1990 35. Quirke, p., Durdey, P., Dixon, M.F., Williams, N,S.: Local recurrence of rectal carcinoma due to inadequate surgical excision. Lancet 2:996, 1986 36. Cawthorn, S.J., Parums, D.V., Gibbs, N.M., A'Hern, R.P., Caf. ferey, S.M., Broughton, C.I.M., Marks, C.G.: Extent of mesorectal spread and involvementof lateral resection margin as prognostic factors after surgery for rectal cancer Lancet 335:1055, 1990 37. Editorial. Breaching the mesorectum "Lancet 335:1067, 1990 38. COrder, h,.p., Karanjia, N.D,, Williams, J.D., Heald, R,J,: Colonic vascular ligation in low anterior resection of the rectum for carcinoma. Br. J. Surg. 77:1422, 1990
857 39. Heald, R.J., Ryall, R.D.H.: Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 2:1479, 1986 40, Dixon, A.R., Maxwell, W.A., Thornton-Holmes, J.: Carcinoma of the rectum: A 10 year experience. Br. J. Surg. 78:308, 1991 41. Galloway, D.J., Cohen, A.M., Shank, B., Friedman, M.A.: Adjuvant multimodality treatment of rectal cancer. Br. J. Surg. 76:440, 1989 42. Gerard, A., Buyse, M., Nordlinger, B.: Preoperative radiotherapy as adjuvant treatment of rectal cancer: Final results of the European Organisation for Research on Treatment of Cancer (EORTC). Ann. Surg. 208:606, 1988 43. Pahlmann, L., Glimelius, B., Graffman, S.: Pre- versus postoperative radiotherapy in rectal carcinoma: An interim report from a randomised multicentre trial. Br. J. Surg. 72:961, 1985 44. Fisher, B., Wolmark, N., Rockette, H.E.: Postoperative adjuvant chemotherapy or radiation therapy for rectal: results from NSABP Protocol R01. J. Natl. Cancer Inst. 80:21, 1988 45. Krook, J.E., Moertel, C.G., Gunderson, L.L., Wieand, H.S., Collins, R.T., Beart, R.W., Kubista, T.P., Poon, M.A., Meyers, W.C., Mailliard, J.A., Twito, D.I., Morton, R.F., Veeder, M.H., Witzig, T.E., Cha, S., Vidyarthi, S.C.: Effective surgical adjuvant therapy for high risk rectal cancer. New Engl. J. Med. 324:709, 1991 46. McDonald, P.J., Heald, R.J.: A survey of post-operative function after rectal anastomosis with circular stapling devices. Br. J. Surg. 70:727, 1983 47. Goligher, J.C., Graham, N.G., DeDombal, F.T.: Anastomotic dehiscence after anterior resection of the rectum and sigmoid. Br. J. Surg. 57:109, 1970 48. Fielding, L.P., Stewart-Brown, S., Blesovsky, L., Kearney, G.: Anastomotic integrity after operations for large bowel cancer: A mutticentre study. Br. Med. J. 1:411, 1980 49. Tagart, R.E.B.: Restorative rectal resection: An audit of 220 cases. Br. J. Surg. 73:70, 1986 50. Shorthouse, A.J., Bartram, C.I., Eyers, A.A., Thompson, J.P.S.: The water soluble contrast enema after rectal anastomosis. Br. J. Surg. 69:714, 1982 51. Schrock, T.R., Deveney, C.W., Dunphy, J.E.: Factors contributing to leakage of colonic anastomoses. Ann. Surg. 177:523, 1973 52. McGinn, F.P., Gartell, P.C., Clifford, P.C., Brunton, F.J.: Staples or sutures for low colorectal anastomoses: A prospective randomised trial. Br. J. Surg. 72:603, t985 53. Everett, W.G., Friend, P.J., Forty, J.: Comparison of stapling and hand suture for left sided large bowel anastomosis. Br. J. Surg. 73:345, 1986 54. Beart, R.W., Kelly, K.A.: Randomised prospective evaluation of the EEA stapler for colorectal anastomosis. Am. J. Surg. 141:143, 1981 55. Irvin, T.T., Goligher, J.C.: Aetiology of disruption of intestinal anastomoses. Br. J. Surg. 60:461, 1973 56. Fazio, V.W.: Sump suction and irrigation of the presacral space. Dis. Colon Rectum 21:401, 1978 57. Karanjia, N.D., Corder, A.P., Holdsworth, P., Heald, R.J.: Risk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis. Br. J. Surg. 78:196, 1991
World Journal of Surgery © 1992 by the Soci~t~ lnternalionale de Chirurgie
Results of Radical Surgery for Rectal Cancer R.J. Heald, M.A., M.Chir., F . R . C . S . , F . R . C . S . ( E d . ) and N.D. Karanjia, M.S., F . R . C . S . , F . R . C . S . ( E d . ) Colorectal Research Unit, Basingstoke District Hospital, Basingstoke, England. This paper examines the hypothesis that a reduction in the distal mural margin during anterior resection for sphincter conservation in rectal cancer excision is safe, provided total mesorectal excision is undertaken with wash-out of the clamped rectum. One hundred ninety-two patients underwent anterior resection and 21 (1 cm et 42, une marge 1 cm y 42 de 1 cm (95% CI: 0.8%0-7.8%) y ninguna en el grupo - 1 cm. L a r e d u c c i r n en el margen de reseccirn, por consiguiente, no pareci6 comprometer la sobrevida despurs de una r e s e c c i r n anterior. Se discute el significado de los m ~ g e n e s laterales de r e s e c c i r n , asf como el papel de ta radioterapia profunda y de los agentes citot6xicos. Ante las bajas tasas de recurrencia local que se logran con cirugfa adecuada, es la opinirn de los autores que tales modalidades tienen poco que ofrecer en el manejo del c~ncer del recto tratado con tal tipo de cirugia radical (RTM). Finalmente, se analizan los resultados funcionales observados luego de una r e s e c c i r n anterior y RTM y se discute el problema del escape anastomrtico. References 1. Walker, A.R.P., Burkitt, D.P.: Colon cancer: Epidemiology. Semin. Oncol. 3:341, 1976 2. Office of Population Censuses and Surveys: Mortality statistics, Cause, England and Wales. Series DH2. 12:8, 1985 3. Bradpiece, H.A., Benjamin, I.S., Halevy, A.: Major hepatic resection for colorectal liver disease. Br. J. Surg. 74:324, 1987 4. Silverberg, E.: Cancer Statistics. New York, American Society, 1981 5. Heald, R.J.: Multiple primary cancers of the bowel. In Risk Factors and Multiple Cancer, B.A. Stoll, editor, Chichester, John Wiley and Sons, 1984, pp. 367-377 6. Handley, W.S.: The surgery of the lymphatic system. Br. Med. J. •:922, 1910 7. Cote, P.P.: The intramural spread of rectal carcinoma. Br. Med. J. 1:431, 1913 8. Grinnell, R.S,: Distal intramural spread of carcinoma of the rectum and rectosigmoid. Surg. Gynecol. Obstet. 99:421, 1954 9. Quer, E.A., Dahlin, D.C., Mayo, C.W.: Retrograde intramural spread of carcinoma of the rectum and rectosigmoid. Surg. Gynecol. Obstet. 96:24, 1953 t0, Williams, N.S., Dixon, M.F., Johnston, D.: Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: A study of distal intramural spread and of patients survival. Br. J. Surg. 70:!50, 1983 11. Miles, W.E.: The radical abdomino-perineal operation for cancer of the rectum and of the pelvic colon. Br. Med. J. 2:941, 1910 12. Miles, W.E.: Cancer of the rectum. London, Harrison, 1926 13. Dukes, C.E.: The spread of cancer of the rectum. Br. J. Surg. /7:643, 1930 14. Wood, W.Q., Wilkie, D.P.D.: Carcinoma of the rectum: An anatomico-pathological study. Edinb. Med. J. 40:321, 1933 15. Dukes, C.E.: Cancer of the rectum: An analysis of 1000 cases. J. Pathol. Bacteriol. 50:527, 1940 16. Goligher, J.C., Duthie, H., Nixon, H.: Surgery of the anus, rectuna and colon. London, Bailliere Tindall, 1985 17. Hojo, K., Koyama, Y., Moriya, Y.: Lymphatic spread and its
R.J. Iteald and N.D. Karanjia: Radical Surgery for Rectal Cancer prognostic value in patients with rectal cancer, Am. J, Surg. 144:350, 1982 18. Hojo, K., Koyama, Y.: The effectiveness of wide anatomical resection and radical lymphadenectomy for patients with rectal cancer. Jpn. J. Surg. 12:111, 1982 19. Hojo, K.: Postoperative follow up studies on cancer of the colon and rectum. Am. J. Surg. 143:293, 1982 20. I-Ieald, R.J., Ryall, R.D.H., Husband, E.: The mesorectum in rectal cancer surgery: Clue to pelvic recurrence. Br. J. Surg. 69:613, 1982 21. Goligher, J.C., Dukes, C.E., Bussey, H.J.R.: Local recurrences after sphincter saving excisions for carcinoma of the rectum and rectosigmoid Br J Surg. 39:199, 1951 22. Finlay, I.G., "IVlc,~rclle,C.S.: Occult hepatic metastases in colorectal carcinoma. Br. J. Surg. 73:732, 1986 23. Ridge, J.A., Daley, M.: Treatment of colorectal hepatic metastases. Surg Gynecol Obstet. •6•:597, 1985 24. Welch, j'.p., Donaldson, G.A.: The clinical correlation of an autopsy study of recurrent colorectal cancer. Ann. Surg, 189:496, 1979 25. Killingback M , Wilson, E , Hughes, E.S.R.: Anal metastases from carcinoma of the rectum and colon. Aust. N. Z. J. Surg. 34:I78, 1965 26. Lockhart-Mummery, J.p.: Resection of the rectum for cancer. Cancer I02:, 1920 27. Kraske, p.: Zur Exstirpation hochsitzender Mastdarmkrebse. Verh. Dtscht Ges. Chir. 14:464, 1885 28. Miles, W.E.: A method of performing abdomino-perineaI excision for carcinoma of the rectum and of the terminal part of the pelvic colon. Lancet 175:1812, 1908 29. Hartmann, H.: Nouveau procede d'ablation des cancers de la pattie 30. ~rminale du colon pelvien. Congr. Franc. Chir. 30:411, 1921 tJ~xon, C.F.: Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann. Surg. 128:425 1948 rucuon of 31. Goligher, J.C.: The use of stapling devices for the const " low rectal anastomoses. Ann. Chir. Gynaecol. 69:125, 1980 32. ~eading Article: Colorectal surgery: The Cinderella specialty. Br.
ed. J. 283"169, 1981 m s R T A colour 33. Lockhart-Mummery, H E , Heald, R.J., Hutch" g , . .: atlas of anterior resection of the rectum. London, Wolfe Medical Publications 1983, 64 pp 34. Karanjia N ' D , Schache, D J North, W.R.S., Heald, R.J.: The close shave in anterior reseciion Br J. Surg. 77:510, 1990 35. Quirke, p., Durdey, P., Dixon, M.F., Williams, N,S.: Local recurrence of rectal carcinoma due to inadequate surgical excision. Lancet 2:996, 1986 36. Cawthorn, S.J., Parums, D.V., Gibbs, N.M., A'Hern, R.P., Caf. ferey, S.M., Broughton, C.I.M., Marks, C.G.: Extent of mesorectal spread and involvementof lateral resection margin as prognostic factors after surgery for rectal cancer Lancet 335:1055, 1990 37. Editorial. Breaching the mesorectum "Lancet 335:1067, 1990 38. COrder, h,.p., Karanjia, N.D,, Williams, J.D., Heald, R,J,: Colonic vascular ligation in low anterior resection of the rectum for carcinoma. Br. J. Surg. 77:1422, 1990
857 39. Heald, R.J., Ryall, R.D.H.: Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 2:1479, 1986 40, Dixon, A.R., Maxwell, W.A., Thornton-Holmes, J.: Carcinoma of the rectum: A 10 year experience. Br. J. Surg. 78:308, 1991 41. Galloway, D.J., Cohen, A.M., Shank, B., Friedman, M.A.: Adjuvant multimodality treatment of rectal cancer. Br. J. Surg. 76:440, 1989 42. Gerard, A., Buyse, M., Nordlinger, B.: Preoperative radiotherapy as adjuvant treatment of rectal cancer: Final results of the European Organisation for Research on Treatment of Cancer (EORTC). Ann. Surg. 208:606, 1988 43. Pahlmann, L., Glimelius, B., Graffman, S.: Pre- versus postoperative radiotherapy in rectal carcinoma: An interim report from a randomised multicentre trial. Br. J. Surg. 72:961, 1985 44. Fisher, B., Wolmark, N., Rockette, H.E.: Postoperative adjuvant chemotherapy or radiation therapy for rectal: results from NSABP Protocol R01. J. Natl. Cancer Inst. 80:21, 1988 45. Krook, J.E., Moertel, C.G., Gunderson, L.L., Wieand, H.S., Collins, R.T., Beart, R.W., Kubista, T.P., Poon, M.A., Meyers, W.C., Mailliard, J.A., Twito, D.I., Morton, R.F., Veeder, M.H., Witzig, T.E., Cha, S., Vidyarthi, S.C.: Effective surgical adjuvant therapy for high risk rectal cancer. New Engl. J. Med. 324:709, 1991 46. McDonald, P.J., Heald, R.J.: A survey of post-operative function after rectal anastomosis with circular stapling devices. Br. J. Surg. 70:727, 1983 47. Goligher, J.C., Graham, N.G., DeDombal, F.T.: Anastomotic dehiscence after anterior resection of the rectum and sigmoid. Br. J. Surg. 57:109, 1970 48. Fielding, L.P., Stewart-Brown, S., Blesovsky, L., Kearney, G.: Anastomotic integrity after operations for large bowel cancer: A mutticentre study. Br. Med. J. 1:411, 1980 49. Tagart, R.E.B.: Restorative rectal resection: An audit of 220 cases. Br. J. Surg. 73:70, 1986 50. Shorthouse, A.J., Bartram, C.I., Eyers, A.A., Thompson, J.P.S.: The water soluble contrast enema after rectal anastomosis. Br. J. Surg. 69:714, 1982 51. Schrock, T.R., Deveney, C.W., Dunphy, J.E.: Factors contributing to leakage of colonic anastomoses. Ann. Surg. 177:523, 1973 52. McGinn, F.P., Gartell, P.C., Clifford, P.C., Brunton, F.J.: Staples or sutures for low colorectal anastomoses: A prospective randomised trial. Br. J. Surg. 72:603, t985 53. Everett, W.G., Friend, P.J., Forty, J.: Comparison of stapling and hand suture for left sided large bowel anastomosis. Br. J. Surg. 73:345, 1986 54. Beart, R.W., Kelly, K.A.: Randomised prospective evaluation of the EEA stapler for colorectal anastomosis. Am. J. Surg. 141:143, 1981 55. Irvin, T.T., Goligher, J.C.: Aetiology of disruption of intestinal anastomoses. Br. J. Surg. 60:461, 1973 56. Fazio, V.W.: Sump suction and irrigation of the presacral space. Dis. Colon Rectum 21:401, 1978 57. Karanjia, N.D., Corder, A.P., Holdsworth, P., Heald, R.J.: Risk of peritonitis and fatal septicaemia and the need to defunction the low anastomosis. Br. J. Surg. 78:196, 1991
