Trattamento chirurgico del carcinoma del retto sottoperitoneale

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Giuseppe Pappalardo, Domenico Spoletini, Aldo Nunziale, Elena Manna, Francesca De Lucia, Fabrizio Maria Frattaroli

Ann. Ital. Chir., 2010; 81: 255-264

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AIM: To value the results of “open” surgery with sphincter preservation, TME nerve-sparing, fast-track, without a protective
stoma in a consecutive series of patients with subperitoneal rectal cancer (s.p.r.c.).
MATERIALS AND METHODS: In January 1989, we started a prospective, non-randomized study designed to assess when a
primary derivative stoma was warranted in a series of consecutive patients electively treated with open low and ultralow
AR. The inclusion criteria were: all patients with middle and low rectal cancer who underwent elective low and ultralow
AR, including those treated with neoadjuvant therapy. The exclusion criteria were: urgent surgery, incomplete rings in
the stapler, a positive hydropneumatic test, preoperative involvement of the external sphincter and/or surrounding structures
by the tumor as demonstrated by CT-scan and endorectal MR and/or transrectal ultrasound. Anastomoses between
7 cm and 4 cm from the pectinate line were defined as low colo-rectal anastomoses, while anastomoses lower than 4
cm from the pectinate line were defined as ultralow anastomoses. A fistula or anastomotic dehiscence was suspected when
pelvic and/or peritoneal pain, fever, leucocytosis, fecaloid liquid in the drainage and/or perianal erythematosus swelling
were present. An anastomotic leak was confirmed by means of angio-CT and/or endoscopy and/or contrast enema depending
on the procedure available most promptly. Signs of peritoneal reaction were considered to be indicative of a major
dehiscence, regardless of the diameter of the fistula; when diagnosed, a transverse colostomy was immediately performed.
Clinically less serious cases were defined as minor dehiscences, for which a “wait and see” strategy or a transcutaneous
CT or ultrasound guided drainage of an abscess were used. Sixtyfive patients were treated according to a fast-track postoperative
protocol.
RESULTS: Between 1998 and 2007, 89 patients with s.p.r.c. were treated according to a prospective protocol. One hundred
and nineteen patients (69.6%) underwent low anastomoses and 52 patients (30.4%) underwent ultralow anastomoses.
Forty-two (24.6%) were treated with traditional AR, 129 (75.4%) with AR and nerve-sparing TME. Forty-six
(26.9%) patients underwent neoadjuvant therapy. One hundred and two patients underwent a mechanical end-to-end
anastomosis, 67 a double stapled anastomosis, and 2 a colo-anal anastomosis at the pectinate line performed according
to our technique. All 6 patients with major dehiscences underwent a protective colostomy within hours of the onset of
clinical symptoms immediately after the radiologically- or endoscopically-confirmed diagnosis. The 7 minor dehiscences
were successfully treated with conservative therapy (antibiotic and enteral feeding) using an out-patient regimen. Two
(28.6%) required percutaneous drainage: one pelvic CT-guided drainage and the other (an ultralow dehiscence) perineal
drainage. The 72.6% of the patients survived at 5-years follow-up. The incidence of local recurrences in 2-years followup
was 3.2% (on 124 patients). We had no deaths in patients treated with fast-track protocol.
CONCLUSION: Open, TME nerve-sparing A.R. with selective use of neoadjuvant therapy, can be successfully performed
without a protective stoma in more than 80% of the patients. Fast-track protocol seems to increase quality of p.o. period
and decrease hospital stay.

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