Stage I rectal cancer: identification of high-risk patients

BACKGROUND: Stage I rectal cancer (T1, T2 N0) is currently treated by surgical resection alone. Despite adequate surgical resection, approximately 10-15% of patients will develop recurrence. Identification of patients at high risk for recurrence could potentially lead to an improvement in outcome by selection of these patients for adjuvant therapy. METHODS: Between June 1986 and September 1996, 211 patients with primary rectal cancer (stage I) were treated by radical surgical resection alone. The medical data of all patients were entered into a database and prospectively followed. The following 10 prognostic factors were correlated with recurrence and tumor-related mortality: patient factors: age, gender, and preoperative carcinoembryonic antigen level; tumor factors: location from the anal verge (< 6 cm vs. > or = 6 cm), T stage (T1 vs. T2), intratumoral blood vessel invasion (BVI), intratumoral lymphatic vessel invasion, presence of tumor ulceration, and histologic differentiation; and treatment-related factors: extent of surgical resection--abdominal perineal resection versus low anterior resection. Univariate analysis of the effect of the prognostic factors on recurrence and tumor-related mortality were performed by the method of Kaplan-Meier and log rank test. Independent prognostic factors were determined by a multivariate analysis performed using the Cox proportional hazards model. RESULTS: The overall 5-year actuarial recurrence was 12% and tumor-related mortality was 10%. Independent predictors of recurrence were male gender and BVI. Independent predictors of tumor-related mortality were male gender, BVI, and poorly differentiated tumors. CONCLUSIONS: Despite radical resection, patients with stage I rectal cancer with male gender, BVI, and poorly differentiated tumors should be considered high-risk patients.     

Adjuvant therapy of colorectal carcinoma--1998 status]

Colorectal cancer is the second leading cause of cancer death in western countries. The prognosis is strongly correlated to the TNM-staging system and patients with stage T3-4 and/or node positive disease are at high risk for locoregional or distant relapse. It is now widely accepted that patients with node positive colon cancer should be offered postoperative adjuvant chemotherapy. Evidence is accumulating that six months' adjuvant fluorouracil plus leucovorin is equivalent to twelve months' fluorouracil and levamisole, which reduces cancer related deaths by more than 30%. Other adjuvant treatment approaches are perioperative regional chemotherapy or monoclonal antibody treatment, and the results of trials comparing these different treatment options alone or in combination are eagerly awaited. In rectal cancer, the risk of locoregional recurrence can be more than 50% and this event is associated with a deterimental effect on quality of life. The technique of mesorectal excision and the use of radiotherapy, alone or in combination with chemotherapy, have evolved as the most important measures for prevention of locoregional recurrence. In addition, chemotherapy has proven to be effective in reducing metastatic relapse and prolonging survival. The timing of radiotherapy (pre- versus postoperative) and the optimal combination of chemotherapy with radiation are presently important research issues in resected rectal cancer. In both colon and rectal cancer, a common theme emerging from the experience of the last few decades is that administration of dose-intensive fluorouracil is key for the success of adjuvant treatment.     

Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis

BACKGROUND: Anal sphincter function is increasingly preserved following rectal excision for cancer and provides a better quality of life for patients than does a permanent colostomy. However, anastomotic complications may cause considerable morbidity and mortality. This retrospective study examined the incidence of anastomotic complications following two forms of reconstruction after resection for mid-rectal cancer: colonic pouch-anal anastomosis (CPAA) and low colorectal anastomosis (LCRA). METHODS: Some 258 consecutive patients with mid-rectal cancers between 6 and 11 cm from the anal verge underwent proctectomy with mesorectal excision and either CPAA or LCRA. The incidence of clinical and radiological leaks was determined in these patients who were considered in three groups: LCRA (defunctioning stoma), LCRA (no defunctioning stoma) and CPAA (all defunctioned). RESULTS: In the LCRA group without a defunctioning stoma, a clinical leak occurred in 17.0 per cent, compared with two of 30 in the LCRA group with a defunctioning stoma. In the CPAA group a clinical leak occurred in 4.9 per cent of patients, which was not significantly different from the rate in those with a defunctioned LCRA. Patients with a non-defunctioned LCRA were more likely to suffer a clinical anastomotic leak (P=0.01), peritonitis (P=0.001) and require unscheduled reoperation (P=0.006) than those with a defunctioned LCRA and/or CPAA. CONCLUSION: The use of a protective defunctioning stoma is advocated in conjunction with LCRAs.     

Hospital doctors, general practitioners and dentists learning together

BACKGROUND: Recurrent melanoma of the extremity has been treated by local excision, systemic chemotherapy, amputation, or a combination of these approaches. Hyperthermic isolated limb perfusion (HILP) provides a method of limb preservation through isolation, allowing the administration of chemotherapy in higher doses than is possible through systemic treatment. METHODS: An experimental group of 59 HILP patients with melanoma recurrences of the extremity was studied prospectively. A control group of 248 melanoma patients with similar recurrences was excluded from HILP because their recurrences were in non-extremity locations. The experimental group underwent HILP and excision; the control group had excision only. The experimental procedure consisted of vascular isolation of the affected extremity and a 1-hour perfusion with melphalan. Temperatures were maintained at 40 degrees C in the perfusion circuit. RESULTS: The HILP patients had a lower rate of locoregional recurrence (P=.028) and demonstrated increased survival (P=.026) compared to the control group. In multivariate regression analysis, which included age, ulceration and thickness of the primary, and the treatment variable of perfusion, age (P=.02) and perfusion for the treatment of recurrence (P=.006) were significant predictors of survival. CONCLUSIONS: HILP improves prognosis by sterilizing the treated extremity, controlling locoregional disease, and perhaps preventing metastasis, thus having a positive impact on overall survival.     

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence?

PURPOSE: This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery. METHODS: During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumor of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence. RESULTS: Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank, P = 0.01 and P = 0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank, P = 0.38). CONCLUSIONS: When mesorectal excision is performed, circumferential margin involvement is more an indicator of advance disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.     

Influence of surgery on metachronous distant metastases and survival in rectal cancer

PURPOSE: Total mesorectal excision (TME) and other technical surgical factors reduce local recurrence rate in rectal cancer. Scientific evidence of the positive effect of optimal surgery on survival is locking. Whether a reduction in the incidence of distant metastases can be achieved with optimal surgery is uncertain. We examine the effects of the quality of surgery, as reflected by local recurrence rate, on survival and the incidence of initial distant metastases. PATIENTS AND METHODS: Between 1974 and 1991, 1,581 consecutive patients who underwent curative resection (RO) for rectal carcinoma were monitored for recurrence and survival. TME was introduced in 1985. No patient received adjuvant radiotherapy or chemotherapy. The median follow-up time was greater than 13 years. RESULTS: The local recurrence rate decreased from 39.4% to 9.8% during the study period (P < .0001). The observed 5-year survival rate improved from 50% to 71% (P < .0001). Three hundred six patients with local recurrence had a significantly lower observed 5-year survival rate (P < .0001). A total of 1,285 patients had no local recurrence, but 275 of them developed distant metastases (International Union Against Cancer [UICC] stage I, 8%; stage II, 16%; stage III, 40%). Better-quality surgery had no effect on the incidence of initial distant metastases, which remained constant (P = .44). CONCLUSION: Quality of surgery is an independent prognostic factor for survival in rectal cancer, but has no influence on initial occurrence of distant metastases. Local recurrence cannot be considered an outcome criterion of adjuvant treatment without consideration of the surgeon as a risk factor.     

Sphincter preservation therapy for distal rectal carcinoma: a review

BACKGROUND: There has been increasing interest in the use of sphincter-preserving therapy for patients with distal rectal carcinomas. The outcomes of conservative treatments for early stage rectal carcinoma appear to be comparable to that achieved with abdominoperineal resection. METHODS: Retrospective and prospective clinical series of patients with distal rectal carcinoma treated by local excision alone, local excision with postoperative adjuvant therapy, preoperative radiation followed by local excision, or radical circumferential sphincter-sparing surgeries were reviewed. The local control rates, salvage rates, and treatment complications in patients treated by these various methods were examined. RESULTS: Patients with T1 distal rectal carcinoma with favorable clinical and histopathologic characteristics treated with local excision alone had a local control rate of greater than 90% in most series. Postoperative chemoradiation improved local control for those with T1 disease with unfavorable characteristics, or those with T2 disease. Most T3 patients had failure rates of greater than 30% despite adjuvant local and systemic therapy. With high dose preoperative radiation, approximately 80% of patients with locally advanced or unresectable tumors were able to undergo sphincter-preservation treatment. CONCLUSIONS: Patients with favorable T1 rectal carcinoma are likely to be adequately treated with local excision alone. Patients with T1 disease with unfavorable characteristics as well as T2 patients will benefit from postoperative chemoradiation. The use of local therapy in T3 patients needs to be carefully considered because these patients are at relatively high risk for local recurrence despite adjuvant therapy. Preoperative radiation followed by either local excision or radical circumferential sphincter-sparing resections appears promising in allowing sphincter preservation in patients with locally advanced tumors.     

In vivo surface analysis of titanium and stainless steel miniplates and screws

OBJECTIVE: To determine the results peranal excision for rectal carcinoma. DESIGN: Retrospective case series. SETTING: A university-affiliated hospital. PATIENTS: Of 178 patients who presented for curative resection of rectal carcinoma between 1975 and 1993, 19 (10.7%) were deemed suitable for local excision. There were 10 men and 9 women with a mean age of 71.2 years. The follow-up ranged from 13 to 184 months. INTERVENTION: Peranal excision. MAIN OUTCOME MEASURES: Histologic differentiation, gross morphology, depth of invasion and size of the carcinoma, adequacy of margins of excision, complications of operation, rates of recurrence, results of salvage therapy and 5-year survival. RESULTS: There were no intraoperative complications. Postoperative complications included urinary retention (one patient) and bleeding (one patient). There were five local recurrences (26%). Salvage operations were performed in three (60%) patients and were successful in two of them. The 5-year cancer-specific survival rate was 82%. The recurrence rate was higher in patients with inadequate margins of excision and ulcerative lesions. Neither size nor grade of the carcinoma correlated with recurrence. CONCLUSIONS: Local excision of rectal carcinoma can be performed successfully in selected patients. Diligent follow-up is required, because up to 60% of local recurrences can be treated successfully.     

Coordinated activity of the new "rectum" and anal sphincter after sphincter-saving resection of the rectum for colitis or carcinoma

PURPOSE: The aim of this study was to determine whether coordinated activity exists across a stapled enteroanal anastomosis. METHODS: Twenty-nine patients were studied for a median of one year after complete excision of the rectum and stapled enteroanal anastomosis; 12 patients underwent low anterior resection with coloanal anastomosis for carcinoma, and 17 patients underwent restorative proctocolectomy with ileoanal anastomosis. RESULTS: Maximum anal resting pressures were slightly lower after coloanal anastomosis than after ileoanal anastomosis [median range, 56 (11-60) cm H2O, cf 69 (40-107) cm H2O, P = NS]. During distention of the neorectum, anal sphincter pressures at 2.5, 1.5, and 0.5 cm from the anal verge were significantly lower after coloanal anastomosis compared with after ileoanal anastomosis (P < 0.01 at each station). The volume of neorectal distention required to produce maximal inhibition of the anal sphincter was significantly less after coloanal anastomosis at 50 (range, 20-60) ml of air than after ileoanal anastomosis at 240 (range, 100-420) ml of air (P < 0.01). Minor fecal leakage and urgency of bowel action were significantly more common after coloanal anastomosis (P < 0.01). CONCLUSION: Alterations in the dynamic response of the anal sphincter to distention of the neorectum may explain why the clinical results were better after ileal pouch-anal anastomosis than after coloanal anastomosis.     

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.     

Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum

BACKGROUND: The goal of this study was to compare patterns of recurrence and long-term outcome after sphincter-saving procedures (SSPs) and abdominoperineal resection (APR) in patients with tumors located in the lower third of the rectum. METHODS: We reviewed the charts of 1001 patients operated on for primary rectal adenocarcinoma between 1980 and 1991. All patients with tumors located between 5 and 7 cm from the anal verge and treated with curative intent were included. RESULTS: Of the 261 patients who met our criteria, 162 had undergone SSP and 99 had undergone APR. The local recurrence rates for SSP and APR were 8% and 11%, respectively (p = 0.41), and the distant metastases rates were 23% and 28%, respectively (p = 0.35). Recurrence and distant metastases rates for SSP and APR, respectively, did not differ by TNM classification: state I, 10% versus 9% (p = 0.9); stage II, 25% versus 43% (p = 0.13); and stage III, 56% versus 57% (p = 0.92). Five-year disease-free survival rates for SSP and APR patients were 70.5% and 62.3%, respectively (p = 0.2). CONCLUSIONS: Tumors in the lower third of the rectum can be treated with sphincter-saving procedures without compromising the chance of cure.     

Local treatment of rectal cancer

While abdominoperineal resection with permanent colostomy is still required for most distal [corrected] rectal cancers, sphincter-saving local treatment by means of local excision, electrocoagulation or endocavitary contact radiation can be used for some highly selected distal tumors. Local treatment avoids a permanent colostomy and is associated with much lower morbidity and mortality rates than abdominoperineal resection. Strict criteria for patient selection are essential to successful local treatment. Optimal candidates include patients exhibiting the following features of rectal cancer: a distal rectal cancer less than 8 cm from the anal verge; a tumor with a diameter of 3 cm or less; a tumor that is well to moderately well differentiated histologically, and a tumor that is limited to the bowel wall. Preoperative studies such as transrectal ultrasonography enhance the accuracy of preoperative staging. In properly selected patients, the results of local treatment are equivalent to those of abdominoperineal resection of comparable tumors. Close follow-up is essential, and tumor recurrence can be treated for cure by abdominoperineal resection.     

The vagina has reducing environment sufficient for activation of Trichomonas vaginalis cysteine proteinases

BACKGROUND AND AIMS: Local excision (LE) may offer an ideal method, instead of standard abdominoperineal excision (APE), for the treatment of low rectal carcinomas, if strict selection criterias are followed. The aim of this study was to evaluate the results after LE and APE, and further compare these two methods. MATERIAL AND METHODS: Thirty-three consecutive patients initially operated on by LE and 83 consecutive patients with radical APE made for tumours in Dukes' stages A to C were reviewed retrospectively. RESULTS AND CONCLUSIONS: The methods did not differ in terms of postoperative mortality and complications, 0/33 versus 1/83 (1%) and 9/33 (27%) versus 32/83 (39%), respectively. Five LEs were palliative and in 23 of the 28 patients, operated on with curative intent, LE alone was considered potentially curative. Local recurrence developed in four (18%) of the 22 patients followed up after curative LEs (14 had a T1 and eight a T2 tumour). In a comparable group of Dukes' stage A tumours, four of the 20 APE patients developed local recurrence. The longterm outcome of patients after LE and APE did not differ in terms of local-recurrence-free survival (80% versus 76%), cancer-specific survival (100% versus 90%) and overall survival (69% versus 76%) at five years, respectively. In conclusion, LE saved the anal continence in properly selected patients with low rectal carcinoma confined to the rectal wall without compromising their outcome. Large prospective series of LEs, however, are needed to assess the importance of factors suggested to increase the risk of local recurrence.     

Adjuvant radiation therapy in resectable rectal cancer: should local recurrence rates affect the decision?

Adjuvant external beam pelvic radiotherapy (XRT) for resectable rectal cancer has been mandated by the National Cancer Institute because of reported 20 to 50 per cent reductions in local recurrence rates. However, these series' reported local recurrence rates are 18 to 39 per cent in the nonradiated patients, which seems extraordinarily high compared to the 3 to 5 per cent rates reported by surgeons advocating proctectomy with complete mesorectal excision. This fact, coupled with the high cost of XRT ($11,000-$14,000), the risk of radiation injury to small bowel and the neo-rectum, and the failure of XRT to provide any survival advantage, raises questions as to the precise role of XRT for rectal cancer. The purpose of this study was to perform a review of 212 consecutive patients undergoing curative resection via low anterior resection (LAR) or abdominoperineal resection (APR) for rectal cancer between 1989 and 1993, focusing on local and distant recurrence rates and survival. The choice of surgery alone (SUR), preoperative radiation (PRE) (45 Gy), or postoperative radiation (POST) (45-50 Gy) was at the surgeon's discretion. There were no significant differences in male:female ratio (SUR, 83:60; PRE, 14:8; POST, 34:13) or type of procedure (SUR-LAR, 112:APR, 31; PRE-LAR, 5:APR, 17; POST-LAR, 30:APR, 17) between the groups. There were no significant differences in age between the preoperative and postoperative radiation groups (PRE, 64.0 +/- 2.4; POST, 59.2 +/- 1.7); however, age was significantly different (P < 0.05) between the surgery-alone and the postoperative radiation groups (SUR, 68.5 +/- 0.8; POST, 59.2 +/- 1.7). With a median follow-up of 49 months, there were no significant differences in local recurrence (SUR, 4.2%; PRE, 4.5%; POST, 2.1%); however, there was a significantly longer survival for the SUR group compared to the other groups (SUR, 45.9 months; PRE, 36.4 months; POST, 39.3 months; P < 0.05 least significant difference). The PRE group also had shorter survival compared to the other groups when only Stage II and III lesions were studied (S, 40.0 months; PRE, 28.3 months; POST, 39.3 months). Local recurrences based on TNM stage were: T1N0 (S, 0 of 27; PRE, 0 of 3); T2N0 (S, 4 of 4S; PRE, 0 of 7); T2N1 (S, 0 of 9; POST, 1 of 5); T3,4N0 (S, 2 of 37; PRE, 1 of 9; POST, 0 of 10); and T3,4N1,2 (S, 0 of 21; PRE, 0 of 3; POST, 0 of 30). The results of this series support the contention that proctectomy with complete mesorectal excision yields a 4.2 per cent local recurrence rate without the need for adjuvant XRT. In this series, if all the patients had received adjuvant radiation, an additional $2.2 million would have been added to the costs of medical care. Therefore, the potential risks, costs, and benefits of adjuvant pelvic XRT for rectal cancer must be weighed against optimal benchmarks for local recurrence rate for surgery alone.     

Clinical results and manometric studies after rectal flap advancement for infra-levator trans-sphincteric fistula-in-ano

Eleven patients with infra-levator trans-sphincteric fistula-in-ano underwent fistula excision with rectal flap advancement. The clinical results were assessed by interview and the physiological function determined by ano-rectal manometry. Nine patients underwent paired studies before and 5 (range 2 to 6) months after operation. Median maximum resting anal pressure was 84 (48-135) cm water before operation and 76 (29-139) cm water after operation (P = N.S.). Median maximum squeeze pressure was 112 (64-290) cm water before operation and 88 (44-316) cm water after operation (P = N.S.). The median sphincter length was preserved after operation. There was one clinical failure following the development of an abscess under the flap. All patients are continent and there have been no recurrences. We conclude that rectal flap advancement is an acceptable way to cure more complex fistula-in-ano. Good functional results are achieved by maintaining anal sphincter function together with preservation of the integrity of the anal margin.     

The fatty acid composition of maternal diet affects the response to excitotoxic neural injury in neonatal rat pups

OBJECTIVE: To determine if perineural invasion (PNI) of small nerves affects the outcome of patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract. DESIGN: Retrospective clinicopathological study of patients with at least 2 years of follow-up and with negative margins and no prior, synchronous, or metachronous SCC. SETTING: Academic otolaryngology department. PATIENTS: One hundred forty-two patients who had SCC of the oral cavity, oropharynx and hypopharynx, or larynx resected between 1981 and 1991. INTERVENTION: Surgery with or without adjuvant therapy. MAIN OUTCOME MEASURES: Local recurrence was examined with respect to PNI, nerve diameter, and microvascular or microlymphatic invasion. Perineural invasion was correlated with lymph node metastasis, extracapsular spread, and survival. RESULTS: Perineural invasion of nerves less than 1 mm in diameter was present in 74 patients, lymphatic invasion in 53, and vascular invasion in 9. Perineural invasion was significantly associated with local recurrence (23% for PNI vs 9% for no PNI; P=. 02), and disease-specific mortality (54% mortality for PNI vs 25% for no PNI; P<.001). With extralaryngeal tumors, PNI was associated with nodal metastasis (73% vs 46%; P=.03). Perineural invasion was not associated with extracapsular spread (P=.47). Microvascular invasion, lymphatic invasion, and nerve diameter were not significantly related to local recurrence. CONCLUSIONS: Perineural invasion of small nerves is associated with an increased risk of local recurrence and cervical metastasis and is, independent of extracapsular spread, a predictor of survival for patients with SCC of the upper aerodigestive tract.     

Surgical treatment of adenocarcinoma of the rectum

OBJECTIVE: The authors' aim was to determine survival and recurrence rates in patients undergoing resection of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant therapy. SUMMARY BACKGROUND DATA: The surgery of rectal cancer is controversial; so, too, is its adjuvant management. Questions such as preoperative versus postoperative radiation versus no radiation are key. An approach in which the entire mesorectum is excised has been proposed as yielding low recurrence rates. METHODS: Of 1423 patients with resected rectal cancers, 491 patients were excluded, leaving 932 with a primary adenocarcinoma of the rectum treated at Mayo. Eighty-six percent were resected for cure. Surgery plus adjuvant treatment was performed in 418, surgery alone in 514. These 514 patients are the subject of this review. Among the 514 patients who underwent surgery alone, APR was performed in 169, CAA in 19, AR in 272, and other procedures in 54. Eighty-seven percent of patients were operated on with curative intent. The mean follow-up was 5.6 years; follow-up was complete in 92%. APR and CAA were performed excising the envelope of rectal mesentery posteriorly and the supporting tissues laterally from the sacral promontory to the pelvic floor. AR was performed using an appropriately wide rectal mesentery resection technique if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. The mean distal margin achieved by AR was 3 +/- 2 cm. RESULTS: Mortality was 2% (12 of 514). Anastomotic leaks after AR occurred in 5% (16 of 291) and overall transient urinary retention in 15%. Eleven percent of patients had a wound infection (abdominal and perineal wound, 30-day, purulence, or cellulitis). The local recurrence and 5-year disease-free survival rates were 7% and 78%, respectively, after AR; 6% and 83%, respectively, after CAA; and 4% and 80%, respectively, after APR. Patients with stage III disease, had a 60% disease-free survival rate. CONCLUSIONS: Complete resection of the envelope of supporting tissues about the rectum during APR, CAA, and AR when tumors were low in the rectum is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. Appropriate "tumor-specific" mesorectal excision during AR when the tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. However, the overall failure rate of 40% in stage III disease (which is independent of surgical technique) means that surgical approaches alone are not sufficient to achieve better long-term survival rates.     

Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection

Constipation and incontinence are frequent complications of rectal prolapse. Surgery should not only aim to correct prolapse but also improve bowel and sphincter function. From 1986-1991 42 patients with procidentia were treated by rectopexy and sigmoid resection. The mean age was 61.1 years. Thirty-nine patients were available for follow-up examination. Mean follow-up was 54 months. Functional data were collected prospectively before the operation and at follow-up and included clinical parameters, a constipation score, an incontinence score, anal manometry [mean resting pressure (MRP), mean maximum pressure (MMP)], proctography [anorectal angle (ARA)] and colonic transit studies [mean transit time (MTT), rectosigmoid transit time (RSTT)]. The postoperative complication rate was 7.1% (n = 3), mortality was 0%. No recurrence was seen. Constipation complaints improved from 43.6% to 25.6% (p < 0.001) and incontinence from 66.6% to 23.1% (p < 0.001). MRP increased from 36.5 mmHg to 46.0 mmHg and MMP from 90.5 mmHg to 103.0 mmHg (p < 0.001). ARA changed from 102 to 98 degrees (p < 0.001) and correlated with sphincter tone and continence. MTT decreased from 47.8 to 38.5 hours, segmental transit (RSTT) from 21.1 to 12.7 hours (p < 0.001). Our results indicate that rectopexy with sigmoid resection is a safe and effective procedure for rectal prolapse and improves functional disorders of bowel and sphincter.     

CO2 laser conization for cervical intraepithelial neoplasia grade II-III: complications and efficacy

PURPOSE: Functional outcome after anterior resection for rectal cancer is improved by colonic J-pouch reconstruction compared with straight anastomosis. The indications for colonic J-pouch reconstruction have yet to be determined. Therefore, we attempted to determine the level at which J-pouch reconstruction provides an advantage over straight anastomosis. METHODS: A total of 48 patients who underwent 5-cm colonic J-pouch reconstruction (J-pouch group) and 80 patients who underwent straight anastomosis (straight group) underwent functional assessment one year postoperatively. RESULTS: The functional outcome in the J-pouch group was significantly better than that in the straight group when the distance of the anastomosis from the anal verge was less than 8 cm. The difference was particularly obvious when the level of the anastomosis was below 4 cm. However, functional outcome in the straight group when the anastomosis was between 9 and 12 cm from the anal verge was also satisfactory and did not differ from that in the J-pouch group when the anastomosis was between 5 and 8 cm from the anal verge. CONCLUSIONS: Colonic J-pouch reconstruction is indicated when the distance of anastomosis from the anal verge is less than 8 cm, and it is essential when the distance is less than 4 cm.     

Successful retransplantation of mouse-to-rat cardiac xenografts under immunosuppressive monotherapy with cyclosporine

BACKGROUND: Total mesorectal excision (TME) is advocated for rectal cancer but the indications and extent of resection vary widely between surgeons. METHODS: Seventy-six consecutive patients (61 elective, 15 acute admission) with rectal or rectosigmoid cancer were admitted to a unit where TME was the preferred surgical option for potentially curative cancer at all levels of the rectum. RESULTS: Procedures undertaken were anterior resection (38 patients), abdominoperineal resection (18), Hartmann's procedure (ten) and transanal excision (one). Six patients had proximal faecal diversion alone and surgery was withheld in three. Anastomotic leaks occurred in six of 37 patients who had anterior resection with primary anastomosis, resulting in one early death. The presence of a proximal stoma did not influence the rate or seriousness of anastomotic dehiscence. After potentially curative TME in 45 patients, there have been eight local recurrences, four associated with systemic metastases and four which occurred in isolation (median follow-up 34 months). CONCLUSION: Curative TME was deemed appropriate in 59 per cent of unselected patients with rectal cancer. It was associated with few local recurrences but a morbidity rate that questions its role in treatment of upper third tumours.