Publications

Fixed Rectal Cancer at Laparatomy : a simple operation to protect the small bowel from radiation enteritis

Kennet Smedh, Department of Surgery, Central Hospital, Västerås, Sweden; Brendan J. Moran and Richard J. Heald, Colorectal Research Unit, The North Hampshire Hospital, Basingstoke, UK
Published in European Journal of Surgery, 1997; 163: 547-548

Introduction: If a fixed rectal cancer without distant metastases is found at laparotomy and the tumour is considered irremovable the optimal treatment is to construct a defunctioning stoma, to close the abdomen, and to refer the patient for a full dose of radiotherapy.  The purpose of the radiotherapy is to shrink the tumour so that it can be resected, and most centres give 40-55 Gy over five weeks.  Subsequently on 40-75% of such patients the tumours are rendered resectable after 5-8 weeks.  One of the drawbacks is the development of troublesome enteritis caused by the irradiation of small bowel in the pelvis.  We describe an operation in which the small bowel is excluded from the pelvis by the distal left colon to reduce radiation injury.

Surgical Technique: The left colon is mobilised and divided with a linear stapler approximately at the top of the sigmoid colon to permit construction of a safe terminal colostomy in the left iliac fossa.   The mesentery is divided without damaging the superior rectal pedicle which is carefully preserved.  The distal part of the colon is brought down and across the pelvis in a circular manner and fixed with interrupted sutures to occlude the pelvic inlet

Discussion: Downstaging of tumours that are regarded as irresectable is considered by some authors to be one of the most important radiotheraputic developments in the treatment of rectal cancer.  With this simple technique the small bowel can be kept out of the pelvis and be protected from the extended full-dose irradiation.  The terminal sigmoidostomy is also an easier stoma to live with than the other options.  In the presence of complete obstruction the theoretical danger exists that a blind loop would be created with a risk of "blow out" of the distal stump.  In such a case it would be logical to bring the distal closure to the subcutaneous level in case such a "blow out" occurred.   It would then become a mucous fistula.
     This operation has been done in five cases during the last three years without any complications.  Drungithis short follow-up period, no patient has experienced any complications related to the irradiation and the colon has remained in situ until the subsequent operation.  If preoperative evaluation by clinical examination, transanal ultrasound, computed tomography, or magnetic resonance imaging suggests that the rectal cancer is fixed to surrounding structures and therefore not resectable primarily with safe margins, this procedure is a logical and practical option.  It may be appropriate to attempt the same procedure laparoscopically with the possibility of a faster recovery and fewer adhesions.