Characteristic findings on defecography according to reconstruction method and defecatory disorder following sphincter-saving surgery for rectal cancer.

BACKGROUND AND AIMS: This study used postoperative defecography to characterize morphological features of defecatory disorders in patients following rectal resection. We also evaluated differences in dynamic defecatory condition depending on reconstruction methods for sphincter-saving surgery. MATERIALS AND METHODS: Subjects comprised 62 patients (male/female, 41/21; mean age, 61 years) who underwent defecography after sphincter-saving surgery for rectal cancer. Semisolid barium (100 ml) was introduced into the rectum, and images were taken in a sitting position. Characteristic dynamic findings in defecography were evaluated according to operative methods and were compared with symptoms of defecatory disorders. RESULTS: Defecographic findings closely associated with postoperative defecatory disorder were as follows: (1) low volume of neorectum in patients with worse incontinence grade (p < 0.05), (2) low evacuation fraction in patients with significantly impaired function such as soiling, urgency, and worsened incontinence score (p < 0.05), (3) minor alteration of anorectal angle at evacuation in patients with major soiling and worsened incontinence score (p < 0.05), and (4) barium shadow in the anal canal at rest in patients with urgency (p < 0.05). By reconstruction method, the J-pouch displayed a larger volume than straight anastomosis but a significantly wider anorectal angle than high anterior resection (HAR). Side-to-end anastomosis offered a moderate volume and a sharp anorectal angle as in HAR. CONCLUSIONS: Defecography is useful for visualizing and characterizing defecatory disorders following rectal resection. Based on defecography, J-pouch reconstruction offers advantageous volume, while side-to-end anastomosis provides a more acute anorectal angle for patients who have received rectal resection with low anastomosis. A new reconstruction method offering both advantages was discussed.

Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy.

PURPOSE: Abdominoperineal resection has been the standard surgery for very low rectal cancer located within 5 cm of the anal verge. However, permanent colostomy exerts serious limitations on quality of life. The present study aimed to investigate curability and functional results of intersphincteric resection and additional partial external sphincteric resection for carcinoma of the anorectal junction. METHODS: Thirty-five patients were prospectively studied from November 1999 to September 2002. All patients displayed adenocarcinoma (T3: n = 26; T2: n = 7; T1: n = 2) located between 0 and 2 cm above the dentate line. Abdominotransanal rectal resection with total mesorectal excision was performed in all patients (total intersphincteric resection: n = 14; subtotal intersphincteric resection: n = 5; additional partial external sphincteric resection: n = 6). All patients underwent diverting colostomy, which was closed at a median of six months postoperatively. Twenty patients received preoperative radiochemotherapy. RESULTS: All patients had curative intent with microscopic safety margins (mean surgical cut end: 4 mm; mean distal cut end: 10 mm). No postoperative mortality was encountered. Morbidity was identified in 13 patients (perianastomotic abscess: n = 4; anastomotic leakage and fistula: n = 4; postoperative bleeding: n = 2; wound infection: n = 1; anastomotic stenosis: n = 1; anovaginal fistula: n = 1). One of these patients received a permanent colostomy. Five patients developed recurrence (liver: n = 1; lung: n = 2; local and lung: n = 1; abdominal wall: n = 1) during the median observation period (23 months). Two of these patients underwent curative resection of liver or lung metastases. Twenty-one patients have received stoma closure, and although continence was satisfactory in all, 5 displayed occasional minor soiling 12 months after stoma closure. Anal canal manometry demonstrated significant reduction in maximum resting pressure (median: 50 cmH(2)O at 12 months after stoma closure), but acceptable function results were obtained. CONCLUSION: Curability and anal function were achieved by means of intersphincteric resection without or with additional partial external sphincteric resection. These procedures can be recommended for low rectal cancer patients who are candidates for abdominoperineal resection.

Advanced esophageal cancer with esophago-bronchial fistula successfully treated by chemoradiation therapy with additional endoscopic resection: a case report.

Chemoradiation is potentially curative for esophageal cancer in various stages, but local failure is a major problem. The present case was a 49-year-old male diagnosed with advanced esophageal cancer with an esophago-bronchial fistula and lymph node metastasis. Histological diagnosis by biopsy was adenosquamous cell carcinoma. Chemoradiotherapy comprising intravenous infusion of cisplatin and continuous infusion of 5-fluorouracil with concurrent radiation was initiated in July 1997. In December 1997, after four courses of therapy, partial remission was obtained and the fistula closed with a remnant polypoid lesion at the primary site, which remained even after six courses of treatment. In February 1998, endoscopic polypectomy was performed for the remnant lesion and histological examination revealed that it contained adenocarcinoma cells. Thereafter, no additional treatment was performed and the patient has been disease-free for 3.5 years. This case suggests that additional endoscopic resection is an optional treatment for local failure after chemoradiation.