The extended Hartmann operation as an elective procedure for rectal cancer. A forgotten operation.

The authors describe their experience with the extended Hartmann procedure as the elective and definitive operation in a selected group of 36 patients having primary adenocarcinoma of the rectum. The operations were carried out between 1st January 1978 and 31st December 1989. The average age of the patients was 70 years (range 37 to 84 years). Ten patients had preoperative radiotherapy because of deep infiltration and (or) fixation of the tumor. In this series the Hartmann procedure was chosen because abdomino-perineal excision was not needed and low anterior resection could not warrant acceptable continence. With a Hartmann procedure the risks of a low colorectal or colo-anal anastomosis were avoided while the perineal excision was abandoned. Eight patients had hepatic metastases. The Dukes' classification of the remaining patients was A in two, B in nine and C in 17 patients. Postoperative morbidity was within acceptable limits for this particular patient group. There was no hospital mortality. Twenty patients had a potentially curative resection prior to 31st December 1987, thus making them available for follow-up of at least 2 years. Ten of these patients have been in follow-up without evidence of disease for an average of 76 months (mean 65 months, range 28-123 months). The authors conclude that the procedure is safe and that the remaining rectal stump does not generate morbidity or discomfort. Considering the fact that only two of the 36 patients had a Dukes' A tumor, the low recurrence rate shows that the Hartmann procedure yields satisfactory pelvic radicality.

Advanced rectal cancer in the female: reduction of pelvic recurrence by rectal resection en bloc with hysterectomy and/or posterior vaginal wall excision.

The authors report their experience with 20 female patients with advanced rectal cancer in whom rectal excision was combined with concomitant excision of the uterus and/or posterior vaginal wall. Six patients presented with a malignant fistula between the rectum and the genital tract; 10 had pre-operative radiotherapy, with a total dose of 50 Gy in seven patients and 30 Gy in three. The resection was judged as radical in 18 patients; the specimen was staged as a Dukes' B in eight and a Dukes' C in 10 cases. Three patients died within the follow-up period, due to intercurrent disease, without evidence of recurrence. Seven patients have been followed without evidence of disease for an average of 91 months (range 39-143 months). One patient is alive 5 years after surgery with a pelvic recurrence. Seven patients succumbed to distant metastases alone (n = 4) or to a combination of haematogenous metastases and pelvic recurrence (n = 3). The authors make a plea for local radicality in advanced rectal cancer in female patients, to preserve quality of life in most patients and a cure in some.

The clinical staging of rectal cancer in patients treated by preoperative radiotherapy.

We describe the results of clinical and (or) surgical staging used by the same surgeon to select a group of 41 patients with advanced rectal cancer for preoperative radiotherapy. Fifteen patients with resectable but advanced rectal cancer were subjected to a short course of radiotherapy (30 Gy in 10 days), immediately followed by resection. High dose preoperative radiotherapy (50-56 Gy in 5 weeks) was administered to 26 patients with borderline resectable or fixed cancer. Adequate resection of the tumour was possible in 21 of these 26 patients 4 weeks after the end of the radiotherapy. A total of 36 patients thus underwent resection after preoperative radiotherapy. No radiotherapy related acute or late morbidity was seen. On 31 December 1992 the results were investigated retrospectively. The median time since entering into the study was 87 months (range 27-141). During the follow-up, pelvic recurrence was detected in six patients; one patient had concomitant distant metastases. The local recurrence free survival at 5 years calculated by the Kaplan-Meier method was 72% (95% CI 58-85). Distant metastases without local recurrence developed in 11 patients. The calculated survival at 5 years was 45% (95% CI 30.5-59).

[Treatment strategy and results in primary inoperable rectal cancer]. / Behandlungsstrategie und Ergebnisse beim primär inoperablen Rectumcarcinom.

The authors report their experience with laparotomy in patients with rectal carcinoma to identify those patients with locally non-resectable primary cancer of the rectum who may be treated initially by high-dose radiotherapy. The goal of this so-called "staging laparotomy" is to assess mobility and tumor size by means of bimanual palpation, to stage the abdominal cavity and to create total fecal diversion by performing an endcolostomy in order to condition these patients for maximum tolerance during the protracted radiotherapy course (greater than 50 Gy/5-6 weeks). The formation of an endcolostomy seems to avoid severe morbidity and even mortality of high-dose radiotherapy without delay of further surgery. Twenty-two patients with locally advanced rectal carcinoma were treated in this way. The tumor was resectable in 18 of the 20 patients who underwent relaparotomy after high-dose radiotherapy. Six out of the 13 patients with a radical resection died with evidence of disease during the follow-up (2 with local disease). One patient died with no evidence of disease after 5 years and 6 patients are still alive without disease after an average of 37 months (15-67 months).

Staging laparotomy for inoperable or borderline operable cancer of the rectum.

The authors report their experience with the staging laparotomy as a means of identifying and preparing patients for high-dose preoperative radiotherapy. Twelve patients had clinically unresectable cancers of the rectum. The goal of the staging laparotomy is to assess mobility and tumor size by means of bimanual palpation, to stage the abdominal cavity, and to fashion an end colostomy at the level of the descending colon. Eight patients ultimately underwent radical resection. Three died during follow-up due to hematogenic metastases without recurrent pelvic disease. Five patients are alive with no evidence of disease and have been followed for an average of 34 months (range, 20 to 64 months).

Effect of extent of anterior resection and sex on disease-free survival and local recurrence in patients with rectal cancer.

Results are presented following 119 curative resections for rectal cancer performed on 47 women and 72 men. Throughout the study it was policy to remove part of the female genital tract when the rectal tumour impinged on the uterus and/or the posterior vaginal wall. After a median follow-up of 7.5 years, local recurrence occurred in three of 46 women and 15 of 71 men (P = 0.03). The survival rates at 5 years were 71 per cent for women (95 per cent confidence interval 56-83 per cent) and 60 per cent for men (95 per cent confidence interval 50-71 per cent) (P < 0.05). The risk for distant metastasis was comparable, suggesting an influence of local recurrence on survival. Reduction of the local recurrence rate coincides with the higher proportion of anterior extensions of surgery in women (19 of 47) than in men (two of 72).