Surgical treatment of rectal carcinoma: Contraversies

The results of the operative treatment of rectal carcinoma have been improved in the last decade, both oncological criteria of radicality and patients quality of life. Development of new surgical techniques and modern surgical equipment, resulted in increased number of sphincter-saving procedures. In the same period, dogmatic opinions such as, that the abdorninoperineal resection is more radical than sphincter saving procedures, were abandoned. Modern surgical concepts for treating rectal carcinoma were supported by many prospective studies, but still there are many dilemmas and controversies that should be determined and proved. In the period 01.01.1991 -12.31.1996,286 low anterior stapled resections of the rectum due to rectal carcinoma were performed at the First Surgical Clinic, the Third Department for Colorectal Surgery, Belgrade. There were 57% males and 43% females, median age 59.6 years. The most common localization of tumor was in the distal third of the rectum 181 (63%). Tji the middle third, there were 89 (31%) and in the upper, intraperitoneal third 16 (6%). Histopathological examination revealed adenocarcinoma in all cases. According to the Gunderson-Sosin modification of Dukes classification, there were 14 (4.9%) in stage A, 167 (58.4%) in stage B (B1,B2,B3), 89 (31.1%) stage C (C1,C2,C3) and 16 (5.6%) stage D. According to Broders classification, there were 129 (45%) well differentiated, 142 (50%) moderately and 15 (5%) poorly differentiated tumours. High ligation of the mesenteric vessels was performed in all cases. The splenic flexure was mobilized except in those few where the sigmoid colon was sufficiently long to allow creation of a low anastomosis without tension. Visceral lymphadenectomy with preservation of hypogastric nerves was thus a standard part of the procedure. The nerves were sacrificed or partially preserved only when they were in close proximity to the tumor or when intraoperative (ex tempore) histological examination of enlarged preaortic glands was positive. Transection of the mesorectum was performed when the tumor was in the proximal third of rectum while in all middle and lower third tumours total inesorectectomy was performed. The pelvic plexus and sacral nerves were preserved in all but a few cases where it was impossible because of tumor spread. Lateral, iliac lymphadenectomy was necessary in 4 patients where enlarged obturator nodes were present. Colonic J pouch was performed in two cases to improve functional results. Anastomotic dehiscence was found in 17 patients (5.95%), mostly conservatively treated, except in 6 cases where spreading peritonitis developed requiring operative treatment. There were 9 (3.1 %) postoperative deaths. Recurrence of the disease was registered in 47 (18%) patients. 26 patients were lost from follow-up. At present, the median follow-up is at 54 months (3-9 years). Analysis by the Kaplan-Meier's test shows cumulative survival of 66% at 72 months of the follow-up.