SURGICAL-TREATMENT OF ADENOCARCINOMA OF THE RECTUM

Objective The authors' aim was to determine survival and recurrence ra tes in patients undergoing resection of rectal cancer achieved by abdo minoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant-therapy. Summary Background Data The surgery of rectal cancer is controversial; so, too, is its adjuvant ma nagement. Questions such as preoperative versus postoperative radiatio n versus no radiation are key. An approach in which the entire mesorec tum is excised has been proposed as yielding low recurrence rates. Met hods Of 1423 patients with resected rectal cancers, 491 patients weve excluded, leaving 932 with a primary adenocarcinoma of the rectum trea ted at Mayo, Eighty-six percent were resected for cure. Surgery plus a djuvant treatment was performed in 418, surgery alone in 514. These 51 4 patients are the subject of this review. Among the patients who unde rwent surgery alone, APR was performed in 169, CAA in 19, AR in 272, a nd other procedures in 54. Eighty-seven percent of patients were opera ted on with curative intent. The mean follow-up was 5.6 years; follow- up was complete in 92%. APR and CAA were performed excising the envelo pe of rectal mesentery posteriorly and the supporting tissues laterall y from the sacral promontory to the pelvic floor. AR was performed usi ng an appropriately wide rectal mesentery resection technique if the t umor was high; if the tumor was in the middle or low rectum, all mesen tery was resected. The mean distal margin achieved by AR was 3 +/- 2 c m. Results Mortality was 2% (12 of 514). Anastomotic leaks after AR oc curred in 5% (16 of 291) and overall transient urinary retention in 15 %. Eleven percent of patients had a wound infection tab dominal and pe rineal wound, 30-day, purulence, or cellulitis). The local recurrence and 5-year disease-free survival rates were 7% and 78%, respectively, after ARI 6% and 83%, respectively, after CAA; and 4% and 80%, respect ively, after APR. Patients with stage III disease, had a 60% disease-f ree survival rate. Conclusions Complete resection of the envelope of s upporting tissues about the rectum during APR, CAA, and AR when tumors were low in the rectum is associated with low mortality, low morbidit y, low local recurrence, and good 5-year survival rates. Appropriate ' 'tumor-specific'' mesorectal excision during AR when the tumor is high in the rectum is likewise consistent with a low rate of local recurre nce and good long-term survival. However, the overall failure rate of 40% in stage III disease (which is independent of surgical technique) means that surgical approaches alone are not sufficient to achieve bet ter long-term survival rates.