Complete Excision of the Rectum for Carcinoma

Kai Tiaki : the journal of the nurses of New Zealand, Volume XII, Issue 4, 1 October 1919, Page 173

Complete Excision of the Rectum for Carcinoma

Wm. Young

By

M.D., F.R.C. S.E.

Radical operations for cancer of the rectum have m the past been associated with such high mortality (some surgeons placing it at forty and even fifty per cent.) that one hesitated to recommend it. The advance of surgery m recent years, with its improvements m techniq ue, has entirely changed one's point of view. The Mayo's report (Mayo's Clinics,. 1916) that m 1913--14-15, of 277 patients with cancer of the rectum they performed radical operations m 71.8 per cent., with a mortality of only 12.3 per cent.

The operation which they recommend, except for a few cases of a very limited extent, is complete excision of the rectum and pelvic colon by the abdomino-perineal route ; it is an operation similar to that described m Jacobson' s and m Keen' s Surgery as the " Miles " operation. Whilst the Krashe operation w T as a great advance on previous operations, the Miles operation is even a greater advance on the Krashe. The Mayos recommend the two-stage operation, and state that fat patients usually died when the operation was attempted m one stage. In doing this operation they usually leave the second stage, the perineal portion, until six days have elapsed.

Prognosis. — Thirty-three and one third per cent of their cases lived over three years, and twenty-eight and one-third per cent, over five years.

Cause of Mortality. — The chief causes were : — Sepsis, 39.8 per cent. ; nephritis, 13 per cent. ; metastatic tumours, 10.5 per cent. ; haemorrhage, 6.5 per cent.

Since Sepsis is the most common cause of mortality one should make an attempt to reduce the septuity of the bowel by preliminary medication and local douches. By bacteriological tests it has been shown that salol, naphthaline, and Beta naphthol are not efficient bowel antiseptics, but that calomel is, and so is kerol m doses of six mm. (m capsules) three times a day. (Med. Ann., 1915.)

A good pfan is to give castor oil four or five days before the operation, calomel the following day, and kerol three times a day.

I am sorry I have no long series of cases to put before you, but the following is an example of the sort of case which gives satisfaction both to patient and surgeon. In September last, along with Dr. Ewart, I examined, under an anaesthetic, a woman aged fifty. We found a hard mass, about the size of a walnut, m the posterior wall of the rectum ; it was about two and a half inches from the anus and appeared to be freely moveable. A portion removed was reported by the pathologist to be carconomatous. As soon as we received this report — it was nearly three weeks later — we decided to operate from the perineum. Commencing with an incision from anus to sacrum, we removed the coccyx, and explored the rectum posteriorly. We discovered that the mass was larger than we expected, and extended back to the sacrum . We then opened the abdomen supra-pubical-ly and discovered that the case was a suitable one for complete excision of the rectum. Having cut across the sigmoid and sewn up each end, we brought the proximal end out through the abdominal wall about one and a half inches internal to the left iliac spine and stitched it m position there, ready for colostomy at a later date. The pelvic colon and rectum were dissected loose, and tucked down as far as possible. The parietal peritoneum was then stitched across to the upper surface of the broad ligament and uterus so as to cut off that portion of the pelvis, containing the rectum, from the abdominal cavity. The abdominal wound was then sutured up and perineal operations resumed.

Dissection of the anus and the rectum, with the tumour, Mas completed from below, and they were removed intact along with the pelvic colon and the surrounding fat and cellular tissue. Drainage tubes and packing were inserted into the resulting cavity, and the wound allowed to granulate. Thanks largely to the administration of warm ether, by Dr. Clay, the patient was returned to bed showing little sign of shock.

Five days later the colostomy was completed with the cautery and the packing

removed from the perineum under an anaesthetic. The patient made an uninterrupted recovery, and four months later reported m excellent health with the colostomy working well ; the bowels were well controlled, moving once m twenty-four hours, and that at night. She continues m good health. Notes. — This case illustrated the ease with which the operation may be done where the growth is discovered at an early stage. But complete recovery has been recorded even when the growth has invaded the neighbouring organs, uterus and appendages, bladder and small intestines. Hysterectomy sometimes becomes necessary. We must remember that the disease usually remains a long time local. Mayo found that some patients m whom the rectal glands were involved recovered, but none m whom the inguinal glands were involved. When one sees the misery endured by patients with rectal cancer, m whom the disease has been considered too far advanced for radical cure, and where a colostomy has been performed, one should not

hesitate, unless there are signs of invasion above the brim of the pelvis, or of metastases, to do a radical operation. There are comparatively few cases m which the so-called tube excision of the rectum can be considered a successful radical cure, for the disease has m some cases been shown to extend microscopically two inches lower and four inches higher than the palpable growth ; moreover, unless the union is within the peritoneum a stricture is likely to form. The Krashe operation cured m a limited number of cases, but it showed a high mortality, and without an abdominal exploration it is impossible to be sure of the extent of the disease. There can be little doubt that m most cases of rectal cancer the abdomen should be explored. Having opened the abdomen one is so far on the way to perform the first stage of excision of the rectum. It seems probable that complete excision of the rectum will almost entirely supersede the Krashe operation and its modifications m the same way that for caroinoma of the cervix total hysterectomy has replaced amputation of the cervix.