Impact of multimodal therapy in locally recurrent rectal cancer.

BACKGROUND: The practice of salvaging recurrent rectal cancer has evolved. The aim of this study was to define the evolving salvage potential over time among patients with locally recurrent disease, and to identify durable determinants of long-term success. METHODS: The study included consecutive patients with recurrent rectal cancer undergoing multimodal salvage with curative intent between 1988 and 2012. Predictors of long-term survival were defined by Cox regression analysis and compared over time. Re-recurrence and subsequent treatments were evaluated. RESULTS: After multidisciplinary evaluation of 229 patients, salvage therapy with curative intent included preoperative chemotherapy and/or radiotherapy (73·4 per cent; with 41·3 per cent undergoing repeat pelvic irradiation), surgical salvage resection with or without intraoperative irradiation (36·2 per cent), followed by postoperative adjuvant chemotherapy (38·0 per cent). Multivisceral resection was undertaken in 47·2 per cent and bone resection in 29·7 per cent. The R0 resection rate was 80·3 per cent. After a median follow-up of 56·5 months, the 5-year overall survival rate was 50 per cent in 2005-2012, markedly increased from 32 per cent in 1988-1996 (P = 0·044). Long-term success was associated with R0 resection (P = 0·017) and lack of secondary failure (P = 0·003). Some 125 patients (54·6 per cent) developed further recurrence at a median of 19·4 months after salvage surgery. Repeat operative rescue was feasible in 21 of 48 patients with local re-recurrence alone and in 17 of 77 with distant re-recurrence, with a median survival of 19·8 months after further recurrence. CONCLUSION: The long-term salvage potential for recurrent rectal cancer improved significantly over time, with the introduction of an individualized treatment algorithm of multimodal treatments and surgical salvage. Durable predictors of long-term success were R0 resection at salvage operation, avoidance of secondary failure, and feasibility of repeat rescue after re-recurrence.

Somatic frameshift mutations in DNA mismatch repair and proapoptosis genes in hereditary nonpolyposis colorectal cancer.

An exacerbated genomic instability at simple repeated sequences characterizes cancer of the microsatellite mutator phenotype (MMP). The majority of hereditary nonpolyposis colon cancers (HNPCCs) and about 15% of nonselected ("sporadic") gastrointestinal tumors belong to the MMP pathway of tumorigenesis. Colorectal MMP+ and MMP- tumors exhibit fundamental differences in genotype and phenotype. We have shown previously that "sporadic" MMP+ colon cancers exhibit a paradoxical low incidence of somatic mutations in the p53 tumor suppressor gene and the c-K-ras proto-oncogene. On the other hand, gastrointestinal MMP+ cancers frequently harbor frameshift mutations in genes containing mononucleotide repeats. These include the cell growth regulator gene TGFbetaRII and the proapoptotic gene BAX. We have also recently shown the frequent presence of frameshift mutations in (A)8 and (C)8 tracts within the hMSH3 and hMSH6 DNA mismatch repair genes in sporadic colon cancer of the MMP. Here, we describe the nearly identical incidence of somatic frameshift mutations in these genes in a panel of 27 HNPCC MMP+ cancers: 52% in hMSH3 and BAX and 33% in hMSH6. In contrast, no mutations in any of these genes were found in 10 MMP- cancers of HNPCC patients. These results show that the multistep model for the unfolding of the MMP also applies to HNPCC and further illustrate the importance of the escape from apoptosis in the MMP pathway for gastrointestinal cancer. They also underscore the differences in genotype between tumors with and without enhanced microsatellite instability and the similarities in genotype between tumors of the MMP regardless of their hereditary or sporadic nature.

A National Cancer Institute Workshop on Microsatellite Instability for cancer detection and familial predisposition: development of international criteria for the determination of microsatellite instability in colorectal cancer.

In December 1997, the National Cancer Institute sponsored "The International Workshop on Microsatellite Instability and RER Phenotypes in Cancer Detection and Familial Predisposition," to review and unify the field. The following recommendations were endorsed at the workshop. (a) The form of genomic instability associated with defective DNA mismatch repair in tumors is to be called microsatellite instability (MSI). (b) A panel of five microsatellites has been validated and is recommended as a reference panel for future research in the field. Tumors may be characterized on the basis of: high-frequency MSI (MSI-H), if two or more of the five markers show instability (i.e., have insertion/deletion mutations), and low-frequency MSI (MSI-L), if only one of the five markers shows instability. The distinction between microsatellite stable (MSS) and low frequency MSI (MSI-L) can only be accomplished if a greater number of markers is utilized. (c) A unique clinical and pathological phenotype is identified for the MSI-H tumors, which comprise approximately 15% of colorectal cancers, whereas MSI-L and MSS tumors appear to be phenotypically similar. MSI-H colorectal tumors are found predominantly in the proximal colon, have unique histopathological features, and are associated with a less aggressive clinical course than are stage-matched MSI-L or MSS tumors. Preclinical models suggest the possibility that these tumors may be resistant to the cytotoxicity induced by certain chemotherapeutic agents. The implications for MSI-L are not yet clear. (d) MSI can be measured in fresh or fixed tumor specimens equally well; microdissection of pathological specimens is recommended to enrich for neoplastic tissue; and normal tissue is required to document the presence of MSI. (e) The "Bethesda guidelines," which were developed in 1996 to assist in the selection of tumors for microsatellite analysis, are endorsed. (f) The spectrum of microsatellite alterations in noncolonic tumors was reviewed, and it was concluded that the above recommendations apply only to colorectal neoplasms. (g) A research agenda was recommended.

Intrachromosomal genomic instability in human sporadic colorectal cancer measured by genome-wide allelotyping and inter-(simple sequence repeat) PCR.

We have used genome-wide allelotyping with 348 polymorphic autosomal markers spaced, on average, 10 cM apart to quantitate the extent of intrachromosomal instability in 59 human sporadic colorectal carcinomas. We have compared instability measured by this method with that measured by inter-(simple sequence repeat) PCR and microsatellite instability assays. Instability quantitated by fractional allelic loss rates was found to be independent of that detected by microsatellite instability analyses but was weakly associated with that measured by inter-(simple sequence repeat) PCR. A set of seven loci were identified that were most strongly associated with elevated rates of fractional allelic loss and/or inter-(simple sequence repeat) PCR instability; these seven loci were on chromosomes 3, 8, 11, 13, 14, 18, and 20. A lesser association was seen with two loci flanking p53 on chromosome 17. Coordinate loss patterns for these loci suggest that at least two separate sets of cooperating loci exist for intrachromosomal genomic instability in human colorectal cancer.

High prevalence of Inoue-Melnick virus antibodies in patients with colorectal carcinoma.

The high prevalence of serum neutralizing antibodies against Inoue-Melnick virus (IMV) among American patients with colorectal carcinoma has been confirmed. Sera from 26 patients with colorectal carcinoma along with the identical number of age- and sex-matched patients with non-colorectal neoplasia and normal healthy controls were collected in the Buffalo area. All of the colorectal carcinoma group possessed antibodies against IMV (100%), while antibody positivity for non-colorectal neoplasia and for normal controls were 34.6% and 38.5%, respectively. Geometric mean titers of antibodies to IMV type 1 and type 2 for colorectal carcinoma were 266 and 338, respectively, whereas the mean titers in the other two control groups were less than 10.3. These differences between colorectal carcinoma and the two controls were highly significant (P less than 0.001). The majority of patients with colorectal carcinoma had antibodies to both IMV types 1 and 2.

99mTc-IMMU-4 monoclonal antibody scan in colorectal cancer. A prospective study.

A blinded prospective study of 34 patients with colorectal adenocarcinoma using the Fab' fragment of the anticarcinoembryonic antigen monoclonal antibody type IMMU-4 labeled with technetium 99m was conducted to compare, on a lesion-by-lesion basis, the findings of radioimmunoscintigraphy, preoperative computed tomography, and exploratory celiotomy. Of 115 lesions detected at surgery, 113 were adenocarcinoma. Radioimmunoscintigraphy detected 59 lesions and computed tomography detected 62; both studies combined detected 72. Twenty-nine (54%) lesions missed by radioimmunoscintigraphy and 24 (45%) missed by computed tomography were 1 cm or smaller. When both studies were combined, the sensitivities were 90%, 24%, and 42%, and the specificities were 52%, 86%, and 61% for hepatic, extrahepatic intra-abdominal, and pelvic lesions, respectively. In 10 patients, additional information obtained with the radioimmunoscintigram could have altered the treatment of these patients. In this study, radioimmunodetection scan was complementary to computed tomographic scan in the examination of patients with colorectal carcinoma.

Absorbable mesh sling prevents radiation-induced bowel injury during "sandwich" chemoradiation for rectal cancer.

HYPOTHESIS: Absorbable mesh slings can prevent radiation-induced bowel injury when adjuvant pelvic radiotherapy is given in the early postoperative period. We hypothesized that the mesh sling technique is similarly effective during "sandwich" sequence adjuvant chemoradiation. DESIGN: Retrospective review. SETTING: Tertiary care comprehensive cancer center. PATIENTS: Nonrandomized series of 19 consecutive patients who underwent abdominoperineal resection and received postoperative sandwich sequence chemoradiation at Roswell Park Cancer Institute, Buffalo, NY, between January 1994 and September 1999. INTERVENTIONS: Twelve patients had an absorbable mesh sling placed at the completion of abdominoperineal resection. Seven patients did not have an absorbable mesh sling placed. MAIN OUTCOME MEASURES: Radiotherapy dose and gastrointestinal toxic effects. RESULTS: All 12 patients in the "mesh" group were able to receive full-dose radiotherapy with tumor bed boost (total dose, 54 Gy, 11 patients; 59.4 Gy, 1 patient). Only 3 of 7 patients in the "no mesh" group were able to receive a tumor bed boost (total dose, 46.8 Gy, 1 patient; 50.4 Gy, 3 patients; 54 Gy, 3 patients). Acute gastrointestinal toxic effects were minimal in the mesh group (grade 1, 10 patients; grade 2, 2 patients) compared with the no mesh group (grade 2, 6 patients; grade 3, 1 patients). None of the patients in the mesh group have shown evidence of late gastrointestinal toxic effects. One patient in the no mesh group required surgery for complications of chronic radiation enteritis. CONCLUSIONS: The protective effects of an absorbable mesh sling extend beyond the life expectancy of the mesh itself. Sandwich sequence chemoradiation should not preclude the use of the mesh sling technique.

The management of infectious and noninfectious anorectal complications in patients with leukemia.

BACKGROUND: Infectious and noninfectious anorectal complications may occur in patients undergoing therapy for leukemia. Controversy surrounds the treatment of this problem in immunocompromised patients. STUDY DESIGN: A retrospective review of the medical records of 83 patients with acute or chronic leukemia in whom anorectal disease developed during inpatient therapy for leukemia was performed to determine the initial signs and symptoms, treatment, and outcomes. RESULTS: During a 12-year period, 92 patients with anorectal complications were treated. This series included 25 patients with perirectal abscesses, 22 patients with anal fissures, 18 patients with symptomatic external hemorrhoids, 12 patients with perianal ulcerations, 12 patients with symptomatic internal hemorrhoids, and three patients with fistulas in ano. Overall, 79 (86 percent) of the 92 anorectal complications resolved in 68 of the 83 patients. Increasing periods of neutropenia did not adversely affect the resolution of anorectal disease. Thirteen patients (16 percent) required surgical intervention, most commonly secondary to a perirectal abscess. Incision and drainage was necessary in ten (40 percent) of 25 patients with perirectal abscess, which included five patients with fluctuation and five patients in whom infection failed to respond to medical therapy. CONCLUSIONS: Noninfectious anorectal complications in patients with leukemia respond to nonoperative intervention and rarely progress to a life-threatening infection. Nonoperative intervention in the form of systemic antibiotics and sitz baths is successful in the treatment of infectious anorectal complications. Incision and drainage should be performed when fluctuation is present and in patients whose complications fail to respond to medical therapy.

Gastroduodenal polyps in familial adenomatous polyposis.

A retrospective review of the medical records of 30 patients with familial adenomatous polyposis who underwent oesophagogastroduodenoscopy was performed to evaluate the spectrum of gastroduodenal polyps. Twenty-five patients (83%) had gastroduodenal polyps. Eighteen patients (60%) had gastric polyps and 21 patients (70%) had duodenal polyps. Five patients (17%) had gastric and 20 patients (67%) had duodenal adenomatous polyps. Three patients (10%) died from an upper gastrointestinal tract adenocarcinoma. Three of nine patients with periampullary adenomas had a normal-appearing papilla of Vater. Since gastroduodenal polyps are common in familial adenomatous polyposis, oesophagogastroduodenoscopy should be performed at the time of diagnosis. Biopsy of polyps as well as biopsy of a normal-appearing papilla of Vater should be performed. Due to their malignant potential, if identified, gastroduodenal adenomatous polyps should be destroyed.

Colorectal cancer in patients aged 30 years or younger.

Colorectal cancer (CRC) is believed to carry a grim prognosis in young patients. A retrospective study of patients diagnosed with colorectal cancer at age 30 years or less between 1971 and 1994 was conducted. Statistical analyses were performed using non-parametric one way ANOVA tests and logistic regression models. Sixty-eight of the patients evaluated at our institution were suitable for this study. Risk factors were identified in 28% of patients. The median age at diagnosis was 27 years (range 14-30 years). Fifty-six patients (82%) were Stage III or IV at the time of diagnosis. Twenty-two of the 34 patients who underwent potentially curative surgery had recurring disease at a median of 12 months (range 1-43 months). At a median follow-up of 21.5 months, 54 patients had died from disease. At the time of death, abdominal carcinomatosis and distant disease were the most common patterns of failure. Stage of the primary tumour (P=0.0006) and recurrence (P=0.0001) were the only variables noted to be associated with survival. The stage of the primary tumour and whether the tumour recurred were each associated with survival in patients with colorectal cancer at age 30 years or less.

Utility of mapping lymph nodes cleared from rectal adenocarcinoma specimens.

The lymph node clearing technique improves the detection of lymph nodes in colorectal cancer specimens. The purpose of this study was to determine the utility of mapping the lymph nodes cleared from rectal adenocarcinoma specimens by evaluating the possible relationship between the pattern of lymph node metastases to the site of the recurrent disease. A retrospective medical record review was performed in 40 patients with primary rectal adenocarcinoma. The specimens were analysed by lymph node clearing technique and mapped after surgery. The lymph nodes were mapped according to their location in the cleared specimens. Statistical analysis was performed using the chi 2-test. A total of 1290 lymph nodes were cleared in 40 specimens. Of these, 1126 (87%) lymph nodes were < or = 5 mm. One-hundred and ten (9%) lymph nodes were metastatic. Sixty-seven (61%) of these 110 lymph nodes were 5 mm or less in size. The majority of lymph nodes with or without metastases were in the pelvis, as opposed to an extrapelvic location (P = 0.0001). Eleven patients recurred. In nine of these patients the recurrence showed a direct relationship between the level of metastatic lymph node location (pelvic vs. extrapelvic) and the site of the recurrent disease (loco-regional or systemic, P = 0.05). The majority of lymph nodes, both normal and metastatic, cleared from specimens from rectal adenocarcinoma were < or = 5 mm in diameter. The lymph node mapping technique may help in predicting the site of recurrence.

Is there a role for curative surgery for pelvic recurrence from rectal carcinoma in the presence of hydronephrosis?

BACKGROUND: The prognosis for patients with recurrent rectal adenocarcinoma is not uniformly fatal if one can safely and selectively reoperate on a subset of patients with resectable disease. Even with careful selection, many patients undergo exploratory laparotomy and do not have resectable disease. We have reported that the presence of hydronephrosis in the setting of recurrent rectal carcinoma portends a poor outcome because of invariable association with unresectable disease. The purpose of this study was to update our experience of patients presenting with unilateral or bilateral hydronephrosis and recurrent rectal cancer. METHODS: A retrospective chart review of 142 patients with recurrent rectal cancer evaluated at our institution from January 1989 to December 1999 was performed. RESULTS: Twenty-seven of 142 patients referred for the management of recurrent rectal cancer had unilateral or bilateral hydronephrosis. Fifteen (55%) of these patients had distant metastatic disease. Twelve patients (45%) with hydronephrosis and local recurrent disease on evaluation were analyzed. Six of the 12 patients underwent exploratory laparotomy, with none found to have resectable disease. Their mean survival after diagnosis of recurrent disease was 14 months. CONCLUSIONS: Based on our results, the presence of hydronephrosis (unilateral or bilateral) in recurrent rectal adenocarcinoma portends a survival equivalent to the presence of distant metastasis. Therefore, we do not believe potential curative surgery has a role for patients with locally recurrent rectal adenocarcinoma in the presence of hydronephrosis.

Inguinal lymph node metastases from adenocarcinoma of the rectum.

This study is a retrospective review of 18 patients treated from 1964 to 1990 with inguinal lymph node metastases from rectal adenocarcinoma. Statistical analyses were performed to determine the effects of sex, disease-free interval, extent of inguinal lymph node metastases, and the presence of extranodal disease upon survival. The mean age of patients was 61 years (range 32 to 87). Lymph node metastases were unilateral in 12 patients and bilateral in 6. All 18 patients developed disease at loco-regional sites (pelvis/perineum) either synchronous or metachronous to their development of inguinal lymph node metastases. Survival from the time of diagnosis of inguinal lymph node metastases ranged from 2 to 54 months (median 13.5). There was no statistically significant difference in survival for unilateral versus bilateral inguinal metastases (P = 0.37). The median survival when inguinal lymph node metastases occurred > or = 12 months from diagnosis of the primary tumor was 16 months and 10.5 months when metastases occurred < 12 months after the diagnosis of the primary tumor (P = 0.033). The median survival for patients with isolated metachronous inguinal lymph node metastases was 20 months versus 12 months for patients who developed metachronous inguinal metastases concurrent with other areas of disease (P = 0.045). Although patients with disease-free intervals > or = 12 months and those with isolated inguinal metastases had statistically significant longer median survivals, the overall survival remains poor and all patients died with disease.

Surgery for recurrent rectal adenocarcinoma in the presence of hydronephrosis.

From January 1974 to December 1989, 16 patients with locally recurrent rectal adenocarcinoma and hydronephrosis underwent exploratory celiotomy with curative intent. There were eight males and eight females. The median age was 61 years. Primary rectal adenocarcinomas were treated with abdominoperineal resection in 12 patients and low anterior resection in 4 patients. Four patients underwent adjuvant radiotherapy, one patient adjuvant chemotherapy, and one patient combination therapy. The median disease-free interval between resection of the primary tumor and recurrence was 18 months. Hydronephrosis was unilateral in seven patients (44%), and bilateral in nine patients (56%). Preoperative evaluation indicated that all 16 patients had local pelvic-perineal recurrence or pelvic recurrence alone. Resection was not possible in any of these 16 patients for the following reasons: 5 patients (31%) had pelvic sidewall involvement and carcinomatosis; 3 patients (19%) pelvic sidewall involvement alone; 2 patients (13%) pelvic sidewall involvement and sacral fixation; and 2 patients (13%) had sacral fixation alone. In the remaining four patients, there was pelvic sidewall involvement by tumor and/or synchronous hepatic metastases, carcinomatosis, or sacral fixation. The median survival after exploratory celiotomy was 8 months in the 16 patients who died of their disease. Unilateral and bilateral hydronephrosis appears to be a contraindication for potentially curative surgical resection in recurrent rectal adenocarcinoma.

Rectal cancer in hereditary nonpolyposis colorectal cancer.

BACKGROUND: Hereditary nonpolyposis colorectal cancer (HNPCC) accounts for approximately 2% to 5% of all colorectal cancers. Rectal cancer in HNPCC is not well characterized. METHODS: A retrospective medical record review of HNPCC patients with colorectal cancer diagnosis from December 1948 to December 1999 was performed in an attempt to elucidate the natural history of rectal cancer in HNPCC. Group A consisted of patients diagnosed with rectal cancer as the index colorectal cancer. Group B consisted of patients diagnosed with rectal cancer as a metachronous colorectal cancer. RESULTS: Twenty-five of 104 patients developed rectal cancer in our HNPCC registry. There were 18 patients in group A with a median age at diagnosis of rectal cancer of 48 years (range 24 to 79) and 7 patients in group B diagnosed at a median age of 58 years (range 45 to 68). Three of 18 patients (17%) in group A developed metachronous colon cancers at a median of 203 months (range 27 to 373) from the index rectal cancer. Rectal cancer in group B was diagnosed at a median 245 months (range 51 to 564) from the index colorectal cancer diagnosis. CONCLUSIONS: Rectal cancer in HNPCC is not uncommon. The presentation of rectal carcinoma should not obviate the evaluation for HNPCC in suspected cases.

The clinical and genetic manifestations of hereditary nonpolyposis colorectal carcinoma.

BACKGROUND: Hereditary nonpolyposis colorectal cancer (HNPCC) is a syndrome that affects a significant percentage of the total cancer population but is not easily recognized because of a lack of a distinctive clinical marker such as multiple polyps. DATA SOURCES: The present review discusses the clinical characteristics, pathology, genetics, management, and surveillance of HNPCC. The diagnosis of HNPCC is dependent upon family history. It is defined by the Amsterdam criteria consisting of: (1) 3 or more relatives with histologically verified colorectal carcinoma, 1 of whom is a first-degree relative of the other 2; (2) colorectal carcinoma involving at least two generations; and (3) one or more colorectal carcinoma cases diagnosed at less than 50 years of age. CONCLUSIONS: The diagnosis of HNPCC requires the demonstration of vertical transmission of the syndrome in the family pedigree. Attention should be focused on reports of cancer of all anatomic sites and the determination of site, histology, and age at diagnosis.

Prognosis and recurrence patterns of anal adenocarcinoma.

BACKGROUND: Anal adenocarcinomas are rare cancers, constituting fewer than 10% of all anal cancers. This is a retrospective review of 10 patients with anal adenocarcinoma. PATIENTS AND METHODS: Seven men and 3 women with a median age of 59 years (range 38 to 82) participated in the study. Using the 1976 World Health Organization classification, 4 patients had the rectal type of cancer, 2 had the anal duct type, and 1 had the anorectal fistula type. The 3 remaining patients had unclassifiable tumors with solely extramucosal disease. Seven patients underwent abdominoperineal resection, 1 had a radical vulvectomy and proctectomy, and 2 had local excision. RESULTS: The median survival was 29 months (range 5 to 249). Seven patients developed a recurrence at the following sites: 2 perineal, 5 inguinal, and 5 distant metastases. Five patients died from their disease a median of 28 months after surgery, and 2 patients died of unrelated causes. Three patients are alive at a median of 54 months; 2 of these patients are free of disease and 1 has a perineal recurrence. CONCLUSION: Anal adenocarcinomas were found to be a rare, heterogeneous group of tumors with a poor prognosis despite radical surgery.

Sexual dysfunction, informed consent and multimodality therapy for rectal cancer.

BACKGROUND: This study assessed the presurgical and preradiation discussion of the risk of posttherapy sexual dysfunction among patients who underwent potentially curative therapy for rectal cancer. The incidence of sexual dysfunction after treatment for rectal cancer was then determined. METHODS: A retrospective review of the medical records of 52 consecutive patients who underwent potentially curative procedures for rectal cancer within 15 cm from the anal verge was performed. RESULTS: Presurgical discussion of the risk of sexual dysfunction was not documented in the consent in 37 of 52 patients (71%). Among the 5 males who underwent local excision, none reported posttherapy sexual dysfunction. Of the 6 males who were treated by low anterior resection, only 1 had a postoperative complaint of sexual dysfunction. Five of 15 males (33%) treated with abdominoperineal resection (APR) alone reported postprocedure sexual dysfunction, whereas 6 of 8 males (75%) treated with APR and radiation reported dysfunction. Of the entire female cohort, only 1 of the 16 reported sexual dysfunction posttherapy. CONCLUSION: A discussion of the risks of posttherapy sexual dysfunction was documented for fewer than one third of the patients. Among males after APR, the use of postoperative radiation showed a trend toward an increase in sexual dysfunction. Surgery and/or radiation therapy did not impact on sexual dysfunction in females.

Colorectal cancer: how does it start? How does it metastasize?

Colorectal carcinogenesis is a multistep process with an apparently orderly progression from benign tissue to invasive malignancy and metastases. Yet at the genome level, a considerably more chaotic situation exists, with order arising through the process of natural selection in the midst of genomic instability. Major pathways for colorectal carcinogenesis begin with suppressor loss or acquisition of a mutator phenotype, but there are other pathways known and yet to be described. These pathways result in the natural selection of cells with unstable genomes leading to malignancy and metastases.

Technique for packing the perineal wound after a wide perineal dissection for adenocarcinoma of the rectum.

A technique for packing the perineal wound after a wide perineal dissection performed as part of an abdominoperineal resection is described. An isolation bag is filled with rolled gauze and positioned in the pelvis beneath the sacral promontory. The packing and the bag are removed on the fifth postoperative day. This technique is safe and more tolerable to patients with an open perineal wound after an abdominoperineal resection.