Original Article

Non-restorative surgery for rectal cancer: indications in 2003

T.J. O’Kelly and J.O. Jansen
Colorectal Unit, Department of Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN

Correspondence to: T.J. O’Kelly, Ward 50, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN Email: T.Okelly@arh.grampian.scot.nhs.uk

Introduction Materials and methods Results

Discussion References

Keywords: Rectal cancr, abdominoperineal excision, Hartmann’s procedure, stoma, anterior resection
Surg J R Coll Surg Edinb Irel., 1 December 2003, 342-346

INTRODUCTION
Carcinomas of the middle and distal third of the rectum have traditionally been treated by abdominoperineal excision of the rectum with formation of a permanent colostomy. Technical innovations over the past two decades, however, together with a better understanding of pelvic anatomy, the behaviour of rectal tumours and the role of neo-adjuvant radiotherapy and chemo-radiotherapy, have resulted in an increasing number of patients undergoing restorative surgery.^1-5 A number of studies have shown that, provided oncological principles are observed, local recurrence and survival are not compromised by this surgical strategy. Anterior resection of the rectum with colorectal or coloanal anastomosis is now the treatment of choice for these cancers.^2,6-11 Despite these advances, a subset of patients with tumours that are very distal or locally extensive, or patients with excessive comorbidity, continue to require abdominoperineal resection or a Hartmann’s procedure.^12-15 Sphincter preservation rates reported in the literature vary from 50% to 91%.^{1,2,6,7,9-11,16} Interpretation of this data, however, is made difficult by variations in the denominator used (Table 1). The clinical guideline for treatment of colorectal cancer, published by the Clinical Standards Board for Scotland (CSBS), recommends that the permanent stoma rate for patients with rectal cancer should be no more than 40%.¹⁷ The aim of this study was to determine the proportion of patients not suitable for restorative surgery, despite an aggressive and consistent policy of sphincter preservation, and to re-appraise the validity of the CSBS standards in contemporary practice. Current indications for non-restorative surgery are explored and the emerging role of intersphincteric resection and coloanal anastomosis is discussed.

MATERIALS AND METHODS
Data pertaining to the management of 100 consecutive patients admitted electively over a three-year period (June 1999 to May 2002) for resection of a primary rectal adenocarcinoma were analysed. All patients were under the care of a single consultant surgeon with a specialist interest in colorectal surgery. The case mix reflected this specialist practice and the study was conducted during the first round of the National Colorectal Cancer Screening Pilot.¹⁸ Data were collected prospectively on a computerised audit system (EMAS, Expandable Medical Audit System), and the case records of all patients who had undergone non-restorative surgery were reviewed.

Patients were staged by clinical examination to determine tumour fixity, by abdominal/pelvic computed tomography and by plain film chest radiography. Transrectal ultrasound was used to help stage the primary tumour, if required. All patients received pre-operative bowel preparation (Kleenprep). Deep vein thrombosis prophylaxis was by use of compression stockings, intra-operative pneumatic calf compression and subcutaneous low-molecular weight heparin injections. Antibiotic chemoprophylaxis was based on antibiotic peritoneal and wound lavage with cefotaxime in saline (1mg/kg) and either intravenous co-amoxiclav or trimethoprim and metronidazole (as directed by the hospital’s microbiology department), administered on induction of anaesthesia. The following surgical strategy was employed:

• Cancers of the lower two-thirds of the rectum (4-14cm from the anal verge) were treated by low anterior resection, total mesorectal excision, formation of a stapled colonic ‘J’ pouch, and stapled pouch-anal anastomosis. All pouches were defunctioned with a loop ileostomy

• Tumours of the upper third of the rectum (15-18cm from the anal verge to distal margin of tumour) were treated by high anterior resection, division of the rectum and mesorectum 5cm below the distal margin of the tumour, and handsewn colorectal anastomosis

• Tumours invading the anal canal were treated by abdominoperineal excision

• A Hartmann’s procedure, consisting of resection of a variable length of rectum, with closure of the remaining rectal stump and formation of an endcolostomy, was performed when an anastomosis was considered inappropriate but excision of the anal canal unnecessary.

Patients suffering from rectosigmoid rather than upper rectal tumours were excluded from this study. All operations were performed through a midline incision.

RESULTS
Eighty-one patients underwent primary restorative surgery and 19 patients underwent non-restorative surgery. The gender ratios of the two groups and the median age of patients were similar (63 years in the non-restorative and 64 years in the restorative group; male:female ratio 1.3:1 and 1.2:1, respectively). One patient, who had undergone restorative surgery, died on the day of operation of cardiac failure secondary to a peri-operative myocardial infarction. There were no early deaths in the non-restorative group.

RT: radiotherapy; CRT: Chemoradiotherapy

Analysis of non-restorative procedures: abdominoperineal resections
Twelve patients had low rectal tumours with involvement of the anal canal and underwent abdominoperineal excision of the rectum and anal canal. Of these patients, nine had locally extensive disease and received neoadjuvant radio- or chemo-radiotherapy. Four had an excellent clinical response to this treatment but all had a persisting palpable abnormality in the anal canal which was felt to preclude sphincter preservation. Histological stage of disease following resection is outlined in Table 2. All 12 patients in this group underwent potentially curative surgery, with no demonstrable involvement of distal or circumferential resection margins.

Analysis of non-restorative procedures: Hartmann’s procedures
Seven patients, all of whom had locally extensive tumours of the upper rectum, underwent an unplanned Hartmann’s procedure rather than high anterior resection, as primary anastomosis was considered inappropriate (Table 3). Three of these patients had received neo-adjuvant radiotherapy. Two of the seven patients had liver metastases which were not detected by preoperative staging. Three patients, two of whom had received neo-adjuvant radiotherapy, appeared clinically to have tumour at the circumferential resection margins, although subsequent histological examination demonstrated that this was only true in one case. Of the remaining two patients, one had a tumour surrounded by an intense inflammatory reaction, and the other a marked peri-proctitis associated with previous radiotherapy. Of the seven patients in this group, two were found to have involved circumferential resection margins on histological examination. Both of these patients had received neoadjuvant radiotherapy.

Local recurrence and survival
One of the two patients noted to have involved circumferential resection margins after non-restorative surgery has since died from locally recurrent disease. To date, there have been no other local recurrences in either group. Seven patients have died of metastatic disease, and a further seven have died of other causes. In view of the short and variable duration of follow-up, these figures need to be interpreted with caution.

DISCUSSION
The primary aim of rectal cancer surgery is to achieve loco-regional control of the disease process with acceptable morbidity and mortality. Restoration of intestinal continuity and avoidance of a permanent stoma, although desirable, is a secondary consideration. The CSBS recommended that in patients with rectal cancer not more than 40% of patients should be left with a permanent stoma. Our results show that with a contemporary approach, much lower rates are achievable. Only 12% of the patients described required abdominoperineal excision and a permanent stoma. A further 7% had a potentially reversible end-colostomy as part of a Hartmann’s procedure. Eighty-one per cent of patients with rectal cancer thus underwent primary restorative surgery. Similar results have been reported by other units.^1,11 These findings suggest that the CSBS guidelines should be revised to reflect current practice.

A number of authors have recently reported small series of patients undergoing intersphincteric resections for very low rectal cancers, with partial or complete resection of the internal anal sphincter and colo-anal or colon pouch-anal anastomosis.^2,19,20 This is an exciting development, but because of the limited and, as yet, poorly defined selection criteria and variable functional results, this technique is not suitable for all patients with distal rectal tumours.^2,19,21

Chemo-radiotherapy has been shown to increase sphincter preservation rates, and although four of our patients responded well to neoadjuvant treatment in terms of tumour bulk and final pathological stage, abdominoperineal excision was still considered necessary to ensure complete resection. It is possible that some of the patients who underwent abdominoperineal excision could have had intestinal continuity restored with interspincteric resection and coloanal anastomosis, but further evaluation of the long-term oncological and functional results of this technique is required to define its role in the management of rectal cancer. We believe that until such robust data are available, tumours invading the anal canal should be dealt with by abdominoperineal excision of the rectum and anal canal. Patients with poor sphincter function who are unlikely to cope with the increased functional requirements placed on the sphincter apparatus as a result of losing rectal capacity, may also be offered abdominoperineal excision. Provided there is no tumour extension into the anal canal, even very low rectal cancers can be treated safely by anterior resection.

Traditional surgical dogma dictates that a colorectal/ coloanal anastomosis should be avoided in patients with significant co-morbidity, residual local (unresectable) tumour or high-volume metastatic disease. A more aggressive policy of primary anastomosis, however, could have avoided stoma formation in some of the seven patients who underwent a Hartmann’s procedure, although perhaps at the expense of safety. A decision to proceed with restoration of intestinal continuity in sub-optimal conditions requires careful judgement and following this review we anticipate the number of elective Hartmann’s procedures performed will decrease. More frequent use of frozen section pathology of resection margins may facilitate this.

Surgical treatment of rectal cancer has changed almost beyond recognition over the last two decades. Advances in technology and the continuing evolution of surgical practice are likely to result in further refinement and standardisation. Not all patients with rectal cancer can avoid formation of a stoma but it is important that a permanent stoma is only made in circumstances where it is absolutely necessary. The CSBS guidelines do not reflect acceptable contemporary practice and should be revised. This is particularly pertinent with the likely introduction of population screening for colorectal cancer.

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Copyright: 17 October 2003