The early days of surgery for cancer of the rectum.
Abstract: Long before being aware of tumours elsewhere along the alimentary canal, surgeons from the earliest days of the profession were all too familiar with cancer of the rectum. The vivid local symptoms of rectal bleeding and mucous discharge, bowel disturbance and then intractable local pain, and the ready detection of the growth by a finger inserted into the fundament made diagnosis all too easy and with it, of course, a hopeless outlook for the poor sufferer. Until quite recent times, treatment was entirely palliative, with the use of hot baths, emollient enemas and dilatations of the constricting growth with bougies. Opium and laudanum, (opium dissolved in alcohol), would be prescribed in advanced cases. Some bold surgeons would use the cautery - an iron heated to red heat - to burn down a fungating growth presenting at the anal margin.

KEYWORDS Rectal cancer / Surgery / Tumour
Article Type: Clinical report
Subject: Colorectal cancer (Care and treatment)
Colorectal cancer (Patient outcomes)
Author: Ellis, Harold
Pub Date: 03/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: March, 2012 Source Volume: 22 Source Issue: 3
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 283274429
Full Text: Surprisingly, the first attempt to excise a rectal cancer was carried out as long ago as 1826. This was twenty years before the first use of anaesthesia, (ether, introduced by William Morton in Boston in 1846). The surgeon was Jaques Lisfranc of the Pitie Hospital in Paris. His operation comprised an oval incision around the skin of the anal verge, dissection of the rectum, and amputating it above the growth. This resulted, of course, in the formation of an uncontrollable colostomy discharging through the perineum. Having undergone the unimaginable torture of the operation, the patient now discharged faeces unchecked through the open perineal wound. Within three years, in spite of these terrible disadvantages, Lisfranc had performed nine of these operations.

In 1885, Paul Kraske, now with the double benefits of general anaesthesia and antisepsis, introduced the operation for sacral resection of the rectum which bears his name. The patient was operated on lying on his side or face down. Exposure was obtained by resecting the coccyx and lower part of the sacrum. The peritoneum was opened from below, the sigmoid colon brought down, the tumour resected and the colon anastomosed end to end to the rectal stump. If the tumour was too low to allow reconstruction, a sacral colostomy was established. This procedure became very popular in continental Europe. It had the disadvantages of a high rate of anastomotic breakdown and, of course, of the patient often being left with an unpleasant, difficult to manage colostomy inconveniently sited at the perineum. Its advantages were a relatively low mortality and reasonable survival results. It continued to be used right up to the middle of the 20th century, although it was never taken up with much enthusiasm in this country. This was probably because of the development of the operation of perineal excision of the rectum, pioneered by J.P. Lockhart-Mummery of St. Mark's Hospital, London, in 1907.

In this operation, a preliminary laparotomy was performed and a left iliac fossa colostomy fashioned. Either at the same time, but more often delayed by ten days, the perineal procedure was carried out, with the patient lying semi-prone. The rectum was excised, the colon divided in the upper part of the wound and the blind stump closed. The operation was relatively simple to carry out and, in those pre-blood transfusion days, relatively bloodless, with a mortality of about l0%. Up to the 1930's it was the most common procedure for rectal cancer in this country and in the USA.

The surgeon was Vincenz Czerny, of Heidelberg

Excision of the rectum by a combined abdominal and perineal operation was first performed in 1884. The surgeon was Vincenz Czerny, of Heidelberg, one of the many great names who had trained under Theodor Billroth in Vienna. However, this was not a planned procedure but it was carried out because an attempted sacral excision of a rectal growth was found to be impossible from below and the abdomen had to be opened in order to complete the operation.

It was Ernest Miles, of the Royal Cancer Hospital (later re-named the Royal Marsden Hospital), and the Gordon Hospital, London, who first carried out abdomino-perineal excision of the rectum electively, his first case being operated upon in 1907. Miles had been disturbed by the high rate of local recurrence of the tumour after perineal excision. He had carried out careful postmortem studies of patients who had died of recurrent disease and became convinced of the importance of wide and extensive removal of the rectum, anal canal, adjacent muscles and draining lymph nodes. His first patient was a house-painter aged 55. After abdominal mobilisation of the tumour, division of the bowel and formation of a left iliac colostomy, the abdominal incision was closed, the patient turned onto his right side and the perineal dissection was performed. The cavity of the pelvis was packed with gauze around a tube drain. The great disadvantage of this radical procedure initially was its high mortality. There were no less than 22 deaths in Miles' first 62 cases. This was reduced to 13 deaths in his third 100 operations. Remember, of course, that these operations were carried out before the advent of blood transfusion, modern anaesthetic techniques and antibiotics, all of which greatly reduced the mortality and morbidity of the operation. The introduction of the Lloyd-Davies special adjustable leg rests in 1939 made it practical for two surgeons to operate at the same time from the abdominal and perineal aspects of the patient, and the synchronous-combined abdomino-perineal excision, with two surgical teams, became standard practice in most centres.

The penalty of this operation is, of course, the permanent colostomy. Today, tumours other than those at the lower end of the rectum or of the anal canal itself are treated by resection with anastomosis as low down as the anorectal ring. The introduction of the stapling gun greatly increased the popularity and ease of this restorative operation. The original circular stapler was a Russian invention in the 1970's; each staple had to be loaded, one by one, into the machine by the theatre nurse. There was great relief when the already-loaded cartridges were produced in the U.S.A., even if they were much more expensive!

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Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication March 2010.

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.

About the author

Professor Harold Ellis CBE, FRCS

Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London

No competing interests declared

by Professor Harold Ellis
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.