Sphincter sparing procedures: is it a standard for management of low rectal cancer

The purpose of this study is to determine whether the type of operation, sphincter sparing procedures (SSP) or abdomino-perineal resection (APR) for primary adenocarcinoma of the rectum at or below the peritoneal reflection affects survival and recurrence after curative surgery.

A prospective controlled study of seventy nine patients with low rectal carcinoma was done between January 1999 and March 2003. Two types of operations were done; SSP (43 patients) including a low anterior resection with either double-stapling technique (DST) (18) or hand-sewn colorectal anastomosis (HSA) (25), and APR (36 patients). The outcome factors evaluated were operative time, intraoperative blood loss, mortality, morbidity, disease-free survival and tumor recurrence. Patients have been followed-up for a minimum of 12 months (mean time 32 months).

Out of 43 patients who underwent SSP, there was one mortality, and 7 morbidities. Anastomotic leakage occurred in 4 cases; one patient needed colostomy. In APR group, no mortalities and 6 morbidities were found. Morbidity was similar in both groups. The local recurrence rates for SSP and APR were 13.8% and 22.2%, respectively (p = 0.540), and the distant metastases rates were 11.1% and 8.3%, respectively (p = 1.000). Two-year disease-free survival rates for SSP and APR patients were 73.3% and 66.7%, respectively (p = 0.121). Intraoperative blood loss was significantly lower in SSP groups.

Sphincter saving procedures can be performed to all patients with rectal carcinoma regardless of the site of the lesion so long the distal and lateral margins are clear. Survival and the risk of local recurrence are similar to that obtained by standard abdomino-perineal resection. Unlike abdomino-perineal resection, sphincter saving procedures preserve the continence and give accepted good quality of life.