ABDOMINOPERINEAL EXCISION OF THE RECTUM - AN ENDANGERED OPERATION

PURPOSE: This study was undertaken to test the efficacy of an extreme policy of sphincter conservation by combining precise total mesorectal excision with low stapling techniques and endoluminal lavage to guard against implantation. METHODS: A total of 136 consecutive operations fbr cancer below 5 cm from the anal verge has been prospec tively docu mented and followed for a mean of 7.7 (range, 1-18) years. A total of 105 of the operations were anterior resections (77 percent), and 31 we re abdominoperineal excisions (23 percent), RESULTS: The oncologic res ults in the 105 patients who underwent anterior resections appear grea tly superior to those of the patients who underwent abdominoperineal e xcisions, although the number of abdominoperineal excisions was small (31). Actuarial local recurrence at six years for anterior resection a nd total mesorectal excision was 1 percent for 85 curative procedures and 4 percent for all cases (n = 100), compared with 33 and 47 percent for abdominoperineal excisions (n = 15 and 31). Only four recurrences were observed below the level of the levators, three in the wound of an abdominoperineal excision and one in a stapled anastomosis after a palliative excision. No cases of nodal metastasis in the ischiorectal fossa were observed. CONCLUSION: In a unit specializing in sphincter c onservation, precise total mesorectal excision from above appears onco logically superior to abdominoperineal excision. Three-fourths of pati ents with carcinoma of the lower one-third of the rectum can be offere d sphincter-conserving surgery, although temporary defunctioning is pr obably prudent in such cases. The wound of an abdominoperineal excisio n may be a prerequisite for perineal recurrence, which may often be ca used by implantation.