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Sphincter saving rectum resection is the standard procedure for low rectal cancer

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Aim

To determine the procedure of choice for rectal cancer, particularly low rectal cancer.

Methods

Complete search, according to evidence-based methods, of comparative studies and national surveys published in English since 1990. Selection criteria: comparative studies between abdominoperineal excision (APER) and sphincter-saving operations (SSO) with a minimum of 50 patients presenting cancer in the lower one-third of the rectum, perfect split of cases with cancer located in the lower, middle or upper one-thirds of the rectum, specified numbers of patients treated by surgery alone or combined with radio-chemotherapy, specified length of follow-up with a minimum of 1 year, univariate or multivariate analysis of prognostic factors. Thirty-four studies fulfilling evidence level C were analyzed, including 6,570 patients. Endpoints: operative risk, local disease control, disease free or cancer specific survival and quality of life.

Results

Postoperative morbidity after APER and SSO is comparable and postoperative mortality decreased to 2% or less. The type of surgery was not identified as a prognostic factor in terms of local disease control and survival. Quality of life is significantly inferior after APER. National data reveal an APER rate for cancer of the whole rectum (up to 16 cm) at 50% or above, and SSO still would represent only 32% of the radical resections for low rectal cancer.

Conclusion

All available evidence indicates that SSO should be the procedure of choice for rectal cancer, even in the lower one-third. An APER should only be performed when cancer invades the anal sphincters and negative resection margins cannot be achieved by a SSO.

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References

  1. Amato A, Pescatori M, Butti A (1991) Local recurrence following abdominoperineal excision and anterior resection for rectal cancer. Dis Colon Rectum 34:317–322

    CAS  PubMed  Google Scholar 

  2. Bokey EL, Chapuis PH, Hughes WJ, Koorey SG, Hinder JM, Edwards R (1990) Morbidity, mortality and survival following resection for carcinoma of the rectum at Concord Hospital. Aust N Z J Surg 60:253–259

    CAS  PubMed  Google Scholar 

  3. Fick TE, Baeten CGMI, Von Meyenfeldt MF, Obertop H (1990) Recurrence and survival after abdominoperineal and low anterior resection for rectal cancer, without adjunctive therapy. Eur J Surg Oncol 16:105–108

    CAS  PubMed  Google Scholar 

  4. Dixon AR, Maxwell WA, Thornton Holmes J (1991) Carcinoma of the rectum: a 10-year experience. Br J Surg 78:308–311

    CAS  PubMed  Google Scholar 

  5. Konn M, Morita T, Hada R, Yamanaka Y, Sasaki M, Munakata H, Suzuki H, Inoue S, Endoh M, Sugiyama Y, Ono K (1993) Survival and recurrence after low anterior resection and abdominoperineal resection for rectal cancer: the results of a long-term study with a review of the literature. Jpn J Surg 23:21–30

    CAS  Google Scholar 

  6. Fegiz G, Indinnimeo M, Gozzo P, Del Grande E, Cataldi S, Brozzetti S (1994) Low rectal cancer-What is the choice? Dis Colon Rectum 37 [Suppl] S37–S41

  7. Bokey EL, Chapuis PH, Fung C, Hughes WJ, Koorey SG, Brewer D, Newland RC (1995) Postoperative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon Rectum 38:480–487

    CAS  PubMed  Google Scholar 

  8. Tschmelitsch J, Kronberger P, Prommegger R, Reibenegger G, Glaser K, Bodner E (1995) Survival and local recurrence after anterior resection and abdominoperineal excision for rectal cancer. Eur J Surg Oncol 21:640–643

    CAS  PubMed  Google Scholar 

  9. Zaheer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D (1998) Surgical treatment of adenocarcinoma of the rectum. Ann Surg 227:800–811

    CAS  PubMed  Google Scholar 

  10. Gamagami RA, Chiotasso P, Lazorthes F (1999) Continent perineal colostomy after abdominoperineal resection: outcome after 63 cases. Dis Colon Rectum 42:626–630

    CAS  PubMed  Google Scholar 

  11. Myerson RJ, Picus J, Read TE (2000) Combining chemotherapy with radiation in the adjuvant care of rectal cancer: morbidity of treatment and its impact on management decisions. Perspect Colon Rectal Surg 12:113–129

    Google Scholar 

  12. Heald RJ, Smedh RK, Kald A, Sexton R, Moran J (1997) Abdomino-perineal excision of the rectum-an endangered operation. Dis Colon Rectum 40:747–751

    CAS  PubMed  Google Scholar 

  13. Lavery IC, Lopez-Kostner F, Fazio VW, Fernandez-Martin M, Milsom JW, Church JM (1997) Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum. Surgery 122:779–785

    CAS  PubMed  Google Scholar 

  14. Rullier E, Laurent C, Carles J, Saric J, Michel P, Parneix M (1997) Local recurrence of low rectal cancer after abdominoperineal and anterior resection. Br J Surg 84:525–528

    CAS  PubMed  Google Scholar 

  15. Topal B, Penninckx F, Kaufman L, Filez L, Aerts R, Ectors N, Kerremans R (1998) Outcome after 'curative' surgery for carcinoma of the lower third of the rectum. Br J Surg 85:1118–1120

    Article  CAS  PubMed  Google Scholar 

  16. Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J (1996) Male and female sexual an urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 186:495–502

    Google Scholar 

  17. Enker WE, Havenga K, Polyak MS, Thaler H, Cranor M (1997) Abdominoperineal resection via total mesorectal excision and autonomic nerve preservation for low rectal cancer. World J Surg 21:715–720

    Article  CAS  PubMed  Google Scholar 

  18. Secco GB, Fardelli R, Campora E, Baldi E, Bonfante P, Ferraris R (1999) Local control after curative surgery for cancer of the extraperitoneal rectum. Oncology 56:193–197

    Article  CAS  PubMed  Google Scholar 

  19. Porter GA, Soskolne CL, Yakimets WW, Newman SC (1998) Surgeon-related factors and outcome in rectal cancer. Ann Surg 227:157–167

    Article  CAS  PubMed  Google Scholar 

  20. Bokey EL, Ojerskog B, Chapuis PH, Dent OF, Newland RC, Sinclair G (1999) Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 86:1164–1170

    Article  CAS  PubMed  Google Scholar 

  21. Park YJ, Youk EG, Choi HS, Han SU, Park KJ, Lee KU, Choe KJ, Park JG (1999) Experience of 1446 rectal cancer patients in Korea and analysis of prognostic factors. Int J Colorectal Dis 14:101–106

    Article  PubMed  Google Scholar 

  22. Jatzko GR, Jagoditsch M, Lisborg PH, Denk H, Klimpfinger M, Stettner HM (1999) Long-term results of radical surgery for rectal cancer: multivariate analysis of prognostic factors influencing survival and local recurrence. Eur J Surg Oncol 25:284–291

    Article  CAS  PubMed  Google Scholar 

  23. Williams NS, Johnston D (1983) The quality of life after rectal excision for low rectal cancer. Br J Surg 70:460–462

    CAS  PubMed  Google Scholar 

  24. Frigell A, Ottander M, Stenbeck H, Pahlman L (1990) Quality of life of patients treated with abdominoperineal resection or anterior resection for rectal carcinoma. Ann Chir Gynaecol 79:26–30

    CAS  PubMed  Google Scholar 

  25. Renner K, Rosen HR, Novi G, Holbling N, Schiessel R (1999) Quality of surgery for rectal cancer: do we sill need a permanent colostomy? Dis Colon Rectum 42:1160–1167

    PubMed  Google Scholar 

  26. Grumann MM, Noack EM, Hoffmann IA, Schlag PM (2001) Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg 233:149–156

    Article  CAS  PubMed  Google Scholar 

  27. Francois Y, Nemoz CJ, Baulieux J, Vignal J, Grandjean J-P, Partensky C, Souquet JC, Adeleine P, Gerard J-P (1999) Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomised trial. J Clin Oncol 17:2396–2402

    CAS  PubMed  Google Scholar 

  28. Janjan NA, Khoo vs, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, Allen PK, Lynch PM, Glober G, Wolff R, Rich TA, Skibber J (1999) Tumour downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M.D. Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 44:1027–1038

    Article  CAS  PubMed  Google Scholar 

  29. Hatzidis WT, Solomon MJ, Schnitzler M, Cartmill J, Loder P, Chapuis P (2000) Does the caseload of the pathologist influence the minimum and extended data set of pathology variables reported for rectal adenocarcinoma? Colorectal Dis 2:26–30

    Article  Google Scholar 

  30. Swedish Rectal Cancer Trial (1997) Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 336:980–987

    Article  PubMed  Google Scholar 

  31. Kapiteijn E, Kranenbarg EK, Steup WH, Taat CW, Rutten HJ, Wiggers T, van Krieken JH, Hermans J, Leer JW, van de Velde CJ (1999) Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group. Eur J Surg 165:410–420

    Article  CAS  PubMed  Google Scholar 

  32. Williams NS, Dixon MF, Johnston D (1983) Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patient's survival. Br J Surg 70:150–154

    CAS  PubMed  Google Scholar 

  33. Lazorthes F, Voigt JJ, Roques J, Chiotasso P, Chevreau P (1990) Distal intramural spread of carcinoma of the rectum correlated with lymphnode involvement. Surg Gynecol Obstet 170:45–48

    CAS  PubMed  Google Scholar 

  34. Hermanek P, Hohenberger W (1996) The importance of volume in colorectal cancer surgery. Eur J Surg Oncol 22:213–215

    CAS  PubMed  Google Scholar 

  35. Holm T, Johansson H, Cedermark B, Ekelund G, Rutqvist LE (1997) Influence of hospital- and surgeon-related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapy. Br J Surg 84:657–663

    CAS  Google Scholar 

  36. Hermanek P (1999) Impact of surgeon's technique on outcome after treatment of rectal carcinoma. Dis Colon Rectum 42:559–562

    CAS  PubMed  Google Scholar 

  37. Steele RJC (2000) Outcomes in colorectal cancer. Is there a case for specialization? In: Scholefield JH (ed) Challenges in colorectal cancer. Blackwell, Oxford, pp 29–38

  38. Machado M, Goldman S, Järhult J (2000) Improved results in rectal cancer surgery—an effect of specialization? Colorectal Dis 2:264–269

    Article  Google Scholar 

  39. Royal College of Surgeons and Association of Coloproctology of Great Britain and Ireland (1996) Guidelines for the management of colorectal cancer. Royal College of Surgeons, London

  40. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, Miedema B, Ota D, Sargent D (2001) Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93:583–596

    Article  CAS  PubMed  Google Scholar 

  41. Julious SA, Mullee MA (2000) Crude rates of outcome. Br J Surg 87:8–9

    Article  CAS  PubMed  Google Scholar 

  42. Liguori G, De Manzini N, Balani A, Leggeri A (1989) La place de l'amputation abomino-perinéale dans le traitement chirurgical des cancers du rectum. J Chir (Paris) 126:374–378

    Google Scholar 

  43. Fandrich F, Schroder DW, Saliveros E (1994) Long term survival after curative resection for carcinoma of the rectum. J Am Coll Surg 178:271–276

    CAS  PubMed  Google Scholar 

  44. Pakkastie TE, Luukkonen PE, Jarvinen HJ (1995) Anterior resection controls cancer of the rectum as well as abdominoperineal excision. Eur J Surg 161:833–839

    CAS  PubMed  Google Scholar 

  45. Nymann T, Jess P, Christiansen J (1995) Rate and treatment of pelvic recurrence after abdominoperineal resection and low anterior resection for rectal cancer. Dis Colon Rectum 38:799–802

    CAS  PubMed  Google Scholar 

  46. Ross A, Rusnak C, Weinerman B, Kuechler P, Hayashi A, MacLachlan G, Frew E, Dunlop W (1999) Recurrence and survival after surgical management of rectal cancer. Am J Surg 177:392–395

    Article  CAS  PubMed  Google Scholar 

  47. Penninckx F (2001) Surgeon-related aspects of the treatment and outcome after radical resection for rectal cancer. Acta Gastroenterol Belg 64:258–262

    CAS  PubMed  Google Scholar 

  48. Havenga K, Enker WE, Norstein J, Moriya Y, Heald RJ, van Houwelingen HC, van de Velde CJH (1999) Improved survival and local control after total mesorectal excision or D3 lymphadenectomy in the treatment of primary rectal cancer: an international analysis of 1411 patients. Eur J Surg Oncol 25:368–374

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Abdominal Surgery, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium

    E. Di Betta, A. D'Hoore, L. Filez & F. Penninckx

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  1. E. Di Betta
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  2. A. D'Hoore
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  3. L. Filez
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  4. F. Penninckx
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Correspondence to F. Penninckx.

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Di Betta, E., D'Hoore, A., Filez, L. et al. Sphincter saving rectum resection is the standard procedure for low rectal cancer. Int J Colorectal Dis 18, 463–469 (2003). https://doi.org/10.1007/s00384-002-0474-8

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