Sphincter-saving surgery in low rectal cancer

A correct surgical approach to rectal cancer today has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary and genital functions. Increased understanding of the natural history, the importance of preoperative accurate staging and new surgical techniques may influence future treatment strategies. The aim of this study was to review and make a reappraisal of the role of sphincter-preserving surgery in the treatment of carcinomas of the lower third of the rectum. From January 1999 to June 2004, 63 consecutive total rectal resections were performed at our surgical department. Thirty-five of these patients, who underwent surgery for a primary adenocarcinoma of the distal rectum (3.5 to 8 cm from the anal verge), were reviewed retrospectively. The preoperative clinical assessment was based largely on T staging, tumor size, fixation and distance from the anal verge. Patient stratification, based on the definitive pathological report, was 3 Dukes' stage A (T1 N0), 21 stage B (T2 N0) and 11 stage C (T2-3-4 N+). The distance from the anal verge was > 5 cm in 30 patients and < 5 cm in 5. Sphincter-saving procedures were performed in 28/35 patients (80%); 7 (20%) had abdominoperineal resections of the rectum for very distal, locally extensive tumours or local recurrence (2 patients). The overall recurrence rate was 11.4%. Postoperative morbidity related to the procedures was low: anastomotic leakage occurred in 10.7% (3/28). Perfect continence was documented in 86.3%. The minimum follow-up time is 12 months. Our data, in agreement with the findings of other Authors, appear to bear out the validity of sphincter-saving procedures in the treatment of cancer of the lower third of the rectum. This approach is possible for the majority of patients. Functional results are good, using an accurate nerve-sparing technique, and may be improved by employing a colonic reservoir in selected cases.