Safety and efficacy of low anterior resection for rectal cancer - 681 consecutive cases from a specialty service

Objective To determine perioperative morbidity, survival, and local failure rates in a large group of consecutive patients with rectal cancer undergoi ng low anterior resection by multiple surgeons on a specialty service. The primary objective was to assess the surgical complications associated with preoperative radiation sequencing. Summary Background Data The goals in the treatment of rectal cancer are cur e, local control, and preservation of sphincter, sexual, and bladder functi on. Surgical resection using sharp perimesorectal dissection is important f or achieving these goals. The complications and mortality rate of this surg ical strategy, particularly in the setting of preoperative chemoradiation, have not been well defined. Methods There were 1233 patients with primary rectal cancer treated at the authors' cancer center from 1987 to 1995. Of these, 681 underwent low anter ior resection and/or coloanal anastomosis for primary rectal cancer. The su rgical technique used the principles of sharp perimesorectal excision. Morb idity and mortality rates were compared between patients receiving preopera tive chemoradiation (Preop RT, n = 150) and those not receiving preoperativ e chemoradiation (No Preop RT, n = 531). Recurrence and survival data were determined in patients undergoing curative resection (n = 583, 86%) among t hree groups of patients: those receiving Preop RT (n = 131), those receivin g postoperative chemoradiation (Postop RT, n = 110), and those receiving no radiation therapy (No RT, n = 342). Results The perioperative mortality rate was 0.6% (4/681). Postoperative co mplications occurred in 22% (153/681). The operative time, estimated blood loss, and rate of pelvic abscess formation without associated leak were hig her in the Preop RT group than the No Preop RT group, However, the overall complication rate, rate of wound infection, anastomotic leak, and length of hospital stay were no different between Preop RT and No Preop RT patients. With a median follow-up of 45.6 months, the overall actuarial 5-year recur rence rate for patients undergoing curative resection (n = 583) was 19%, wi th 4% having local recurrence only, 12% having distant recurrence, and 3% h aving both local and distant recurrence, for an overall local recurrence ra te of 7%. The actuarial 5-year overall survival rate was 81%; the disease-f ree survival rate was 75% and the local recurrence rate was 10%. The overal l survival rate was similar between Preop RT (85%), Postop RT (72%), and No RT (83%) patients (p = 0.10), whereas the disease-free survival rate was s ignificantly worse for Postop RT (65%) patients compared with Preop RT (79% ) and No RT (77%) patients (p = 0.04). Conclusion The use of preoperative chemoradiation results in increased oper ative lime, blood loss, and pelvic abscess formation but does not increase the rate of anastomotic leaks or the length of hospital stay after low ante rior resection for rectal cancer. The 5-year actuarial overall survival rat e for patients undergoing curative resection exceeded 80%, with a local rec urrence rate of 10%.