Controversial Issues in Rectal Cancer Surgery

Introduction

Ernest Miles [ 1] postulated that adequate treatment of rectal cancer, regardless of the site and apparent progress of the tumour, in all cases necessitated a wide excision of the entire anorectum and establish- ment of a permanent colostomy by an operation involving both an abdominal and a perineal dissec- tion. Lloyd-Davies confirmed this statement, advo- cating the synchronous combined technique that became by far the most popular method of dealing with rectal cancer worldwide.

However, from the early 1940s onward, sphincter- saving methods, even low anterior resections, were put on trial by several surgeons [ 2]. The results for growths of the rectosigmoid and upper third or half of the rectum proved to be good and with the passage of time surgeons were encouraged to extend the use of these methods to yet lower lesions. One disadvan- tage was that low-sited tumours were often inaccessi- ble for technical reasons, and many different tech- niques were used to overcome this problem [ 3, 4].

Moreover, a handsewn anastomosis was often associ- ated with a high incidence of leaks, fistulae, abscess- es and anastomotic strictures, and the functional results were often unsatisfactory. Although patient satisfaction was stated to be positive in the majority of patients, flatus and/or faecal incontinence were common. Based on a careful assessment of the func- tional results after low anterior resection, Goligher et al. [ 5] concluded that if a rectal stump of at least 6–7 cm could not be preserved, the patient would be bet- ter treated by abdominoperineal resection (APR).

With the advent of stapling instruments allowing mechanical construction of the colorectal anastomo- sis and the contribution of the colon pouch, ultralow anastomoses have become routine procedures per- formed by most general surgeons. Anterior resec- tions (ARs) with anastomosis are now possible at a level that could never be performed by handsuturing.

The lowest rate of permanent stoma formation for rectal cancer in the literature is below 10%, in a unit routinely employing a stapled anastomotic technique

for low anterior resection [ 6], and other specialist units have reported similar low rates [ 7], figures that differ greatly from the more common rates of about 30% [8].

Radicality

Numerous trials have been done over the years to evaluate the oncological merits of the two operations and no difference in the pelvic recurrence rate or dis- ease-free survival has been demonstrated. There are no randomised studies to confirm this and such a study will probably not ever be done. So, the general opinion held is that a correctly performed AR for a rectal cancer should not decrease the curative poten- tial when compared to an APR, and should give as good a long-term cure as the APR.

The appearance of a local pelvic recurrence both after an AR or an APR has been a disappointing event over the years but the recent introduction of total mesorectal excision (TME) – a proper anatomical dissection technique advocated by Heald et al. [ 9], has been a great step forward by reducing the recur- rence rate considerably. Special attention is directed towards the importance of a TME – which rests on the recognition of the distal mesorectum as a possi- ble site of tumour spread – and on the recognition of an inadequate circumferential margin outside the mesorectal fascia [ 10]. Subsequently the removal of the distal mesenteric tongue has been considered excessive as a standard procedure. Therefore – in its present form properly defined – the TME with com- plete excision of the visceral mesorectal tissue down to the level of the levators is recommended mainly for distal mid- and lower rectal cancer (at or below 12–13 cm above the pectinate line); whereas for the upper third or rectosigmoidal cancer a tumour-spe- cific mesorectal excision (TSME) should be pre- ferred, which means a precisely perpendicular and circumferential excision of the mesorectum to the level of an appropriate resection margin distal to the tumour. The current most popular view is that the

Controversial Issues in Rectal Cancer Surgery

Leif Hultèn, Gian Gaetano Delaini, Marco Scaglia, Gianluca Colucci

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distal intramural spread below the tumour is a rare event and a free distal margin of 2 cm below the tumour is considered adequate [11].

Morbidity and Mortality

A sphincter-preserving operation that aims to improve quality of life (QoL) must also be safe to per- form with a low mortality and morbidity and must give a satisfactory functional result.

It is well known that APR is associated with a sig- nificant complication rate both related to the per- ineal wound and the abdominal stoma. In a recent study [ 12] the overall complication rate was reported to be about 60%, the most frequent being urinary tract problems and perineal wound infections. How- ever, even AR proved to be afflicted with an overall complication rate approaching 40%; anastomotic leakage and pelvic sepsis ( 10%) being the most fre- quent. However the adoption of the TME technique leads to an increasing number of low and ultralow colorectal anastomoses and with them an increased complication rate, as reflected in a report from Karanjia et al. [6]. The leakage rate in this study was 18%, mostly in patients with an anastomosis fash- ioned below 6 cm.

Major leaks occurred in 24 of the 219 patients in the study. Three of these patients died and the remaining 21 patients ended up with a permanent stoma. Mortality rates after the two operations seem to be similar, ranging between 2 and 3% [13].

It should be emphasised however that APR and AR are technically and anatomically quite different procedures and therefore not comparable. Problems related to the perineal wound after APR add consid- erably to the morbidity.

Comparative Aspects

The APR has often been referred to as a formidable operation associated with significant changes in body image. Devlin et al. [14] and Williams and Johnston [15] painted a very gloomy picture of colostomy patients’ QoL, the majority suffering from leakage and odour restricting their social life. However, although an AR leaves patients’ body image intact, the procedure may be associated with considerable functional disturbances. Excision of tumours in the mid and distal third of rectum means sacrifice of the major or entire part of the rectal ampulla thereby interfering with the delicate recto-anal nervous con- trol of defecation and continence. Increased evacua- tion frequency, defecation urgency and imperfection of continence is inevitable, occurring in between half

and two thirds of patients, with increasing severity the lower the colo-anal anastomosis [ 16, 17]. The use of pre-operative radiation contributes to further deterioration of function [18].

From these results, it seems that a rectal stump of about 6 cm from the anal verge is necessary to main- tain reasonable recto-anal function, confirming the statement of Goligher et al. [ 5]. As a shorter stump may confer worse function, the fashioning of a short 5–7-cm colon J-pouch or alternatively a coloplasty procedure created by making an 8–10-cm longitudi- nal colostomy above the anastomosis and closed transversely with two layers of sutures has been advocated in an attempt to restore a neo-rectal reser- voir and such trials have proved to be beneficial [ 19, 20]. It should be mentioned however that, apart from being demanding procedures with specific inherent complications, functional imperfections still remain (evacuation difficulties and incontinence) and long- term effects are unknown. The traditional view of low anterior resection seems now to have been modified to comprise total rectal excision with colopouch anal reconstruction as the standard restorative operation for tumours of the mid and lower rectum.

Quality of Life Assessment

Sphincter-saving procedures are today considered to be the first choice in the treatment of even very low sited rectal cancer. One may get the impression that an AR should be done whenever possible and at any cost, restricting the use of APR to a small proportion of cases where the lesion actually invades or approaches very closely to the anal canal. The main reason for this has been the conviction that the QoL for patients with a colostomy after APR was poorer than for patients undergoing a sphincter-preserving technique. However, such statements often date from older reports at a time when sanitary and stomather- apeutic standards were poor [ 15]. Stoma care has improved considerably over the last few decades and the latest generation of stoma appliances provides better patient comfort and a high degree of social convenience. Moreover, patients having a low anteri- or resection may suffer considerably from symptoms affecting their QoL although the problems are in many respects different from those in stoma patients.

Therefore conclusions reached by previous QoL

studies comparing stoma with non-stoma patients

may no longer be valid. The question is therefore still

whether – and if so to what extent – QoL benefits are

to be gained by use of ultralow anastomosis com-

pared with APR and a colostomy. What is the preva-

lence of physical, psychological, social and sexual

dysfunction among patients whose sphincters have

Controversial Issues in Rectal Cancer Surgery

87

been sacrificed compared with those in whom sphincters were preserved?

The results of a careful review of the literature on the subject have recently been published [21]. The Authors identified 25 potential studies. Eight of these – all non-randomised and representing 620 partici- pants – met the inclusion criteria. Four trials found that patients having an APR did not have poorer QoL measures than patients with AR. One study found that the colostomy affected the patients’ QoL only slightly. Three studies found that patients with an APR had significantly poorer QoL than after AR. Due to heterogeneity, meta-analysis of the included stud- ies was not considered justified. The authors con- cluded that the results from the review did not allow firm conclusions as to the question of whether the QoL of patients after AR is superior to that of people after APR and suggested that larger, better designed and executed prospective studies are needed to answer this question.

Are There any Limitations for Advising a Low Anterior Resection and to Whom Should an APR be Recommended?

Most patients think of the stoma as a terrible disaster that might put an end to a normal life and many studies in the past have painted a gloomy picture of the stoma patient’s lifestyle. Therefore the patient’s personal preference would probably be for an opera- tion that retains normal anal function, even at the price of functional imperfections and maybe even a somewhat reduced prospect of ultimate cure. But patients should know the shortcomings of each pro- cedure. Patients have to know that with a properly sited and well constructed stoma, a perfectly fitted stoma appliance and the advice and support of a stoma nurse the patient will be able to lead a normal life. Patients should be informed that despite all pre- cautions taken to avoid technical errors, the risk of anastomotic leaks and pelvic septic complications still remains a problem, particularly after low anasto- mosis; and the post-operative course is unpre- dictable. Patients have to know that such a complica- tion may often be associated with a painful protract- ed post-operative course and a long hospital stay and that in some unfortunate cases the consequences may lead to rectal stump/pouch excision and eventu- ally a permanent colostomy. Even with an uncompli- cated post-operative course the functional result may be far from acceptable and quite a few patients will suffer from increased frequency, urgency, faecal incontinence, and permanent or occasional soiling.

Although alternative neorectal constructions may improve function, they are demanding and risky pro-

cedures, they are still associated with functional imperfections, and it is doubtful if they will stand the test of the time.

Although the curative value and the radicality of the AR and APR are probably similar, the develop- ment of a local pelvic recurrence after a sphincter- saving operation is particularly distressing. The risk of pelvic recurrence may not be greater than after an APR, but a recurrence will give distressing symptoms at an earlier stage. The symptoms are more difficult to manage and may require another major operation, often at a time when the patient may just have recov- ered from the first operation, and this operation will seldom be curative.

Many experienced surgeons would probably advise against a low anterior resection for anaplastic tumours, and otherwise bulky and/or fixed tumours, reserving the operation for mainly local and limited growths, and those with low-grade malignancy. An APR may also be preferable for old age, particularly for those with a short life expectancy and those with a serious contemporary disease (diabetes, cardiac or pulmonary insufficiency etc.). In these patients an

“ultralow” rectal resection – with square stapling of the anorectal remnant, omitting the perineal dissec- tion – would be justified, considerably reducing the operative trauma and post-operative morbidity.

Considering the defecation urgency and imperfec- tions of continence after an AR, it appears reasonable also to advise against the operation for immobile and bedridden patients i.e., for those who have difficulty reaching a toilet in time and for those who for their daily care are dependent on nursing staff.

Summary

Controversy still exists as regards the extent of lym- phadenectomy, the use of the no-touch principle, the optimal free distal margin and importance of the irrigation/washout of the rectal stump in radical sur- gical treatment of rectum. There is in fact no statisti- cal scientific evidence to support any of these meas- ures for improving the oncological cure rate. Neither is there any scientific evidence to support the impor- tance of TME or that an AR for a low sited rectal can- cer does not compromise “radicality”. Randomised controlled studies are lacking and it is doubtful – for ethical reasons – if such studies will ever be done. It would be virtually impossible to organise such a trial of two operations (one of which inflicts and the other avoids a permanent colostomy) because of the diffi- culty of getting patients to agree to enter a scheme that might leave them with an abdominal anus.

“There are two different ways to determine the

best kind of treatment for colorectal cancer, the first

88

of which being the purely scientific way based on sta- tistics and the second being a non-scientific way, the so-called ‘gut feeling’ decision, based on the question

‘what operation would I myself prefer to undergo?’”

[22].

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