First thousand rectal cancer cases--local recurrence and survival

In the period 1990 - 2002, 1674 patients with colorectal carcinoma were operated in the First Surgical Clinic, Third Department for Colorectal Surgery. In 1264 cases (75.5%) rectal carcinoma was the indication for surgical treatment. Sphincter saving procedures (SSP) were performed in 824 (65.2%), abdominoperineal resections (APR) in 340 (26.9%) and resections of rectum with definitive stoma (Hartmann procedure) in 100 (7.9%) patients. We analyzed 1095 cases where curative SSP or APR were performed. All cases where curative resection was not possible because of liver metastases or inability to excise all macroscopic disease were excluded. In the group of patients where SSP was performed (767 cases), there were 26.6% high colorectal anastomoses (8cm from anal verge), 65.4% with low (4-8cm from anal verge) and 8.0% with intersphincteric coloanal anastomosis (cm from anal verge). Patohistological exam showed 5.3% Dukes A, 53.1% Dukes B, 36.5% Dukes C and 4.9% Dukes D. In the APR group (328 cases) there were 1.,5% Dukes A, 32.4% Dukes B, 62.1% Dukes C and 3.5% Dukes D. In this study we analyzed local recurrence and five-year survival in both groups. Recurrence of the disease was registered in 325 (29.6%) out of 1095 patients. Local recurrence was found in 81 (7.,4%) patients. In the SSP group recurrence occured in 215 (28.0%) out of 767 curative resections. Local recurrence alone was found in 53 patients (6.9%). SSP group was also divided into two subgroups; in the first group TME was performed and in second transection of mesorectum was carried out. Analyzing local recurrence in these two groups, in the TME group it was 7.6% and in the transection group 5.6%. In the APR group recurrence was registered in 110 (33.5%) out of 328 patients while local recurrence alone was found in 28 (8.5%) cases. Analyzing mortality we found that 234 (21.4%) out of 1095 patients died during follow-up. In the SSP group 154 out of 767 patients (20.1%) died. In the TME group mortality was 21.7% and in the transection group 16.9%. Mortality in the APR group showed that 80 out of 328 (24.4%) patients died during follow-up. Analysis by the Kaplan-Meier's test shows cumulative survival of 0.69 for all cases. In the SSP group cumulative survival is 0.72 and in the APR group 0.64 with statistically significant difference (p .001). In the TME group cumulative survival is 0.75 and in the transection group 0.,72 with statistically significant difference (p .05). We believe that performing SSP should be encouraged whenever it is possible because there is no difference in local recurrence rates and survival compared to APR. Transection of mesorectum can safely be performed in most cases with tumors located more than 8 cm form anal verge. We believe that exact preoperative staging and preoperative radiotherapy could improve results.