Middle and lower third rectum carcinoma: sphincter saving or abdominoperineal resection?

Sphincter saving resections (SSR) are performed with increasing frequency in carcinoma of the lower and middle third of the rectum. In this retrospective study local and distant recurrence and survival were compared to abdominoperineal resection (APR). In 71 women and 71 men (mean age: 64 years) with a primary adenocarcinoma between 5 and 10 cm from the anal verge 89 SSR, and 53 APR, were performed (Dukes stages--SSR--A 19%; B 30.3%; C 50.7% vs APR--A 15%; B 45.3%; C 39.6%). Patients have been followed up for a minimum of 24 months (mean time 62 months). There were no differences in intraluminal diameters of the tumours in each operative procedure. The distal tumour-free distance was more than 6 cm in 52% after APR (SSR: 10%) and less than 3 cm in 43% after SSR. Survival was not different between procedures in Dukes stages A and B. A survival advantage for patients with Dukes C carcinoma after APR did not reach statistical significance. No differences in distant spread were found for SSR (Dukes stage A 0%; B 7%; C 18%) and APR (Dukes stage A 0%; B 8%; C 14%) for local recurrence in Dukes stages A and B after SSR (A and B 0%) and APR (A 0%; B 8%) whereas a significant increase in local recurrence rate was seen in Dukes stage C after SSR (24% vs, APR 5%). Although a further resection could be performed in almost all of these patients a negative effect of local recurrence on survival occurred (25.4 months with and 80 months without local recurrence). While SSR seems to be favourable in Dukes stages A and B, APR should be considered in carcinoma of the lower and middle third of the rectum with lymphatic spread. Effective preoperative staging determines selection of the appropriate operation.