What can be done to improve the results in colorectal cancer?

It is seldom even under the best of circumstances that more than half the patients suffering from colorectal cancer are cured by conventional surgical management, and the results are often much worse. Attempts to improve this state of affairs have followed 4 main directions, which are here critically examined: 1. earlier (presymptomatic) diagnosis; 2. more radical surgery; 3. adjuvant radio- and chemotherapy; and 4. more meticulous follow-up using CEA monitoring and occasional "second-look" operations.

Current trends in the treatment of colorectal cancer.

In recent years interest in the management of bowel cancer has focussed mainly on two main considerations:- A The prospect of improving the overall curability by:- The achievement of much earlier presymptomatic diagnosis with the aid of Hemoccult screening of sections of the population at risk; The deployment of more radical techniques of operation, especially in regard to rectal cancer; The supplementation of surgical excision with adjuvant radiotherapy and chemotherapy; The development of a more meticulous regime of follow-up after operation, using CEA monitoring and occasional "second look" operations to deal with recurrence. B The greater use of sphincter-saving types of excision for growths of the middle and lower parts of the rectum. To this end several new techniques of rectal resection have become popular--especially the downward extrusion of low anterior resection with the aid of the circular stapler. In addition, for small very favourable low growths local excision or local destruction by diathermy fulguration or contact irradiation have been employed. The rationale and success of these two forms of endeavour are examined.

Judging the quality of life after surgical operations.

In gauging the achievements of surgical treatment it is important to try to measure the quality of functional result vouchsafed to the patient and his capacity for work and recreation. Because the impairments of function that may occur after different operations very considerably, an operation-specific assessment for each type of procedure is essential.

Sphincter-saving excision for cancers of the middle and lower parts of the rectum.

Currently four methods of sphincter-saving excision are in vogue for carcinomas of the middle and lower rectum--low anterior resection with or without the aid of the circular stapler, abdomino-sacral (or abdomino-transphincteric) resection, abdomino-anal resection with endocavitary sutured colorectal or colo-anal anastomosis, and local excision (or destruction by diathermy or contact irradiation). The relative advantages and--as far as is known--the results of these different methods are examined with special reference to anterior resection using the circular stapler, which is now by far the most popular choice.

Extended low anterior resection with stapled colorectal or coloanal anastomosis.

The use of extended low anterior resection with the aid of the circular stapler for carcinomas of the middle third or upper part of the lower third of the rectum is discussed and salient technical points are emphasized. A collective survey of the results of the operation for such growths has led to the following conclusions: The immediate mortality and morbidity are not excessive. In most cases, even with anastomoses as low as 3.5-4.5 cm from the anal verge, anorectal function eventually reaches a satisfactory state, though there may be quite troublesome diarrhoea and possibly some incontinence during the initial 3-6 months after operation. Adequate data regarding 5-year survival are still lacking, but the high incidence of local recurrence in some reports is perplexing and disappointing and demands continued close attention.

Current use of sphincter-saving excision in the radical treatment of rectal cancer.

The author examines the recent increased use of sphincter-saving forms of excision to treat carcinomas of the middle third and upper part of the lower third of the rectum. This trend has been due chiefly to technical innovations--especially the introduction of the circular stapler, which has extended the downward reach of low anterior resection--and the willingness to accept a distal margin of clearance in resections of 2.0 to 2.5 cm instead of 4 to 5 cm. Published data show that these innovations are associated with a low operative mortality and that satisfactory anorectal function can be retained. Insufficient length of follow-up, however, has made it impossible so far to calculate valid long-term survival rates and the high incidence of local recurrence in some reports has been disturbing.

The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine.

Two-hundred and seven survivors of excisional surgery for primary Crohn's disease of the large intestine have been followed for a mean period of 15 years (range, 7 to 25 years). Of the 45 patients who were treated by colectomy and ileorectal anastomosis, 32 (71 percent) developed recurrence in the terminal ileum, rectum, or ileum and rectum, (and in the duodenum in one). Most recurrences appeared during the first few years, but there appeared to be some continuing predisposition to recurrence indefinitely. Nineteen of the patients with recurrences proceeded to rectal excision and ileostomy. A total of 17 patients (3 percent) with or without recurrence had good functional results with a retained ileorectal anastomosis. Of the 162 patients who were treated by ileostomy and colectomy or proctocolectomy (rarely rectal excision and iliac colostomy), 24 (14.8 percent) had recurrences, usually in the bowel immediately above the stoma and, occasionally, more extensively elsewhere. Most recurrences manifested themselves in the first eight to ten years after operation, and the continuing predisposition thereafter was relatively slight. The inconvenience occasioned by the stoma in these 162 patients was rated as nil in 36.4 percent, negligible in 33.3 percent, moderate or severe in 25.3 percent, and ileostomy refashioning was performed in 5.0 percent with improvement in most instances. The overall condition of the 162 patients was considered to be excellent in 71 percent, fair in 22.8 percent, and poor in 6.2 percent.(ABSTRACT TRUNCATED AT 250 WORDS)

Eversion technique for distal mucosal proctectomy in ulcerative colitis: a preliminary report.

A technique is described for assisting the performance of distal mucosal proctectomy in ulcerative colitis by peranal eversion of the lower rectum. The ease, accuracy and expedition of the mucosal excision have been impressive. In 9 of 16 patients having this procedure as part of an ileo-anal anastomosis (with a pelvic ileal reservoir) the functional results seemed to be similar to those obtained in 14 patients submitted to the same operation but with an endocavitary technique of rectal mucosectomy.

The use of pedicled transplants of sigmoid or other parts of the intestinal tract for vaginal construction.

The use of transplants from different parts of the intestinal tract for vaginal construction is surveyed and the special value of sigmoid colon for this purpose is demonstrated by the results obtained in 7 patients treated by the author.