An Experience with Low Anterior Resection of the Rectum for Neoplastic Disease'S

A. ~/V. MARTIN MARINO, SR.,*'* M.D. , A. \V. NIART1N MARINO, .JR., ' :~* , M . D .

Brooklyn, New York

"TuE Hls'roaY of proctology is replete with examples of the search for an opera- tion for cancer of the rectum which would spare the patient a colostomy." With this observation the attthors introduce their excellent presentation. Then they indulge in a historical review in which they men- tion the article by Sir "William Ernest Miles, entitled "A Method of Performing Ab- dominoperineal Excision for Carcinoma of the Rectum and of the Terminal Portion of the Pelvic Colon," publishecl in Lancet in

1908. Among tile many methods described be-

fore and after the Miles report are men.. tioned the following:

Lisfranc6 who, in 1826, removed portions of the anus and rectum and most of the results were discouraging. Kraske -~ popu- larized ,tn operation with a posterior ap- proach, in which the minor-bearing por- tion of tile r e c t u m w a s r e n t o v e d a n d an

anastomosis performed, preserving the anal sphincters. The mortality and recurrence rates were exceedingly high. From 1894 to 1906, sporadic reports on tile combined ab-

*Abridgment of original article read at the joint meeting of the American Proctologic Society and the Section of Proctology of the Royal Society of Medi- cine, Piailadelphia, Pennsylvania, May 9 to 14, 196t.

Winner of the Award of the New York Society of Colon and Rectal Surgeons.

':";~ Senior Attending Procto!ogist (Colo:,~_ and Rec- tal), The Brooklyn-Cumberland Medical Center: Clinical Professor of Surgery, State University of New York, Downstate Medical Center.

#*~Chief, Division of Proctology (Colon and Rectal), The Brooklyn-Cumberland Medical Center: Assistant Clinical Professor of Surgery, State Uni- versity of New York, Downstate Medical Center.

dominoperineal operation appeared in medical literature. In 1903, C. H. Mayo 8 reported on 19 alMominoperineal resections of the rectum, and Miles 't0 classic article ap- peared ill 1908, establishing tile rationale of surgery for malignant disease of the terminal portion of tile large bowel. Mean- while, other investigators were attempting surgical procedures aimed at avoiding colos- tomy, including the technic of Mattnsell, 7

the use of the Murphy 1)utton and the in- tussusception technic of Hochenegg. 4 In 1{)32, Babcock ! renewed interest in proce- dures to preserve tile anal sphincter nms- cles, concerning which there was consider- able controversy. The "perineal anus" was espoused by sonte and decried by others. Then Bacon2 explored further the "pull. Iln'ouglf" operation with the objective of preserving the anal canal. In 1948 Black 3 reported a sphincter-saving procedure which he termed "a combined ab(lomino- endorectal resectiotf' in which a few centi- meters of the terntinal portion of the rec- taI nmcosa is preserved to save the reflex mechanism which maintains anal control. Salvati, 1~ in 1959, reported 10 cases in which this procedure was utilized, and he claimed that this technic was valuable in lesions situated 6 to 12 era. from the anal verge when anterior resection could not be accomplished. In 1!)5! T u r n b u l P -~ 1-e- ported a modified techn'c of abdom~norec- tal pull-through resection with delayed posterior colorectal anastomosis.

Thus far the authors had not mentioned resection and anastomosis, the most direct technic for removal of rectal cancer with

368

LOW ANTERIOR RESEC'TION OI: THE RECTUM 369

preservation o1~ anal function. In 1957, C. W. Mayo 9 reported favorably on anter ior resection of the sigmoid, rectosigmoid and upper portion of the rectum for carcinoma. He reported that anterior resection was possible, in the vast majori ty ot2 cases, for lesions situated 6 to 9 cm. above the den- tate line. He claimed that survival and mortality statistics for this procedure could be compared favorably with those of ab- dominoperineal resection. At the present time, low anterior resection is a well-es- tablished surgical procedure. T o determine the effectiveness of this operation, tl~e au- thors reviewed the records of alI of their patients who underwent cperations at The Brooklyn Hospital for neoplasms of the rectum during the pas~ seven years. No selection of cases was at tempted, all cases being consecutive. The only requirement for "case inclusion" was that only those pa- tients be includedlin whom tile caudad mar- gin of the tumor was not more than 16 cm. nor less than 9 cm. from the anal verge. They admit that sometimes it is technically possible to perform a resection and anasto- mosis when a lesion is situated distal to 9 cm. b u t , i n s u c h instances, they have per- formed an abdominoper ineal resection because less than an acceptable amount of rectum and pararectal tissue, distal to the lesion, might be resected it" the surgeon should be overzealous in his desire to perform a sphincter-preserving operation. However, they believe that anterior resec- tion is preferable to abdominoper ineal re. section when distal spread has already occurred.

Preoperat ive Management

ProctosigmoidoscoDy, a:ad biopsy, o_f re~)- resentative areas of the lesion are always performed. T o determine the extent of in- vasion, an a t tempt is made to remove the specimen from the area of junction of the minor and adjacent bowel wall. If possible,

tile bowel is examined to tile level of 25 cm. from the anal verge.

Roentgenologic study of the colon after administrat ion of a bar ium enema is made of all patients in whom obstruction of the bowel lumen is not of such a degree that administration of bar ium might be dan- gerous. In some instances it is advisable to utilize an absorbable contrast medium such as Gastrograffin.

Preoperatively, tlle attthors obtain the following laboratory tests in all patients about to undergo resection of the bowel: complete blood count, complete urinalysis, Fishberg urine concentration test, blood sugar, urea and creatinine, total serum protein and a lbumin /g lobul in ratio, pro- thrombin time, bleeding and clotting time, electrocardiogram and chest x-ray.

A special consultation, both preopera- tively and postoperatively, is obtained from an internist, who emphasizes evaluation of the cardiopuhnonary system and addit ional tests are performed as required.

Blood pressure is recorded four times a day and the patient 's weight is cha~-ted every other day.

,\ low-residue, hlgh caloric and high pro- tein diet is prescribed, h~cluding milk and fruit juices, and therapeutic doses of mul- tiple vitamins are admhlistered orally. If there has been recent loss of weight, and if the hemic component is depressed, trans. fusions of whole blood are administered prior to operation.

Preparation of the bowel consists of an e,:ema of saline solution daily and admin- istration of Sulfasuxidine,® 0.25 gm. per kg. of body weight daily (in divided closes) for five days prior to operation. Streptomy- cin, 0.5 gin, is administered ora!Iy every six hours, beginni~ag 48 hours preoperatively.

On the (Iay before operation, only a fluid diet is allowed and, at 4:00 p.m., 60 cc. of castor oil is administered. T h a t eve- ning enemas are given unti l the returns are clear and this is repeated carefully three

~}70 MARINO ANI) MARINO

hours pr ior to operation. About an hour before operation, 12 Gm. of Sulfasuxidine® mixed in 90 to 100 cc. of sterile saline solu- tion is inserted into the rectum, and the pat ient is encouraged to retain it.

A retent ion catheter is introduced into the urinary bladder one hour before sur- gery and a t ransparent collection receptacle is provided so that the urinary output can be observed by the surgeon and the anes- thesiologist throughout surgery. T h e au- thors consider that this is pa r t i cu l~ ly valu- able in assessing the patient 's reaction to a prolonged and stressful procedure.

No foods or liquids are allowed during the eight-hour period preceding operation. After anesthesia has been started, a No. 16 plastic Levin tube i s introduced through a nostril into the stomach. Dur ing the course of the prel iminary intra-abdominal palpa- tion, the surgeo n sees that the tip of the tube is situated about two inches proximal to the pylorus, and he guides the anesthesi- ologist in withdrawing excess tubing. T h e gevin tube is then attached to the nostril with adhesive tape. T o drain off retained fluid, a sterile rectal tube is inserted into the rectum immediately b e f o r e the operation.

Technic of Opera t ion

A generous, left, pa ramedian incision is made, extending f rom the pubis to 2 to 5 cm. above the umbilicus. T h e left rectus muscle is dissected free at the midline and retracted laterally. Dry sterile towels are secured to the anter ior rectus fascia on either side, utilizing 15 to 18 towel clips in such a way that the abdominal fat and skin are excluded f rom the operative field. T h e peri toneal cavky is d~en entered in ~he usv, al fashion° Tt~e caudad extension of the peri toneaI incision is carried to the left of the urinary bladder and into the pelvis. Abdominal palpat ion is performed, begin- ning with the r ight lobe of the liver and, at this time, correct placement of the Levin

tube is assured. Once pa lpa t ion and visual- ization of the organs of the uppe r abdomen has been completed, tile small and large bowel and their mesenteries are palpated. T h e pelvis, pelvic organs, colon, rectum, and rectosigmoid are examined last. Often it is impossible to palpate low-lying tumors and, when this si tuat ion is encountered, little time should be spel:t a t tempt ing it.

The pat ient is placed in the Trendelen- burg, position, to a moderaoe,o degree. Often it is desirable to adjust the pat ient to this position gradually from the beginning of the operation. If there are adherent areas in the omentum, they are freed and the omentum is placed anter ior to the stomach. A Balfour type, self-retaining retractor is introduced. Warm, ntoist, laparotomy pads are used to cover the small intestine, which is then lifted out of the pelvis° Failure to accomplish this effectively re- suits in improper exposure of the pelvic colon and rectum and, if fur ther relaxatiou will make it possible, it is well worthwhile to wait until it is accomplished. A Deaver retractor, four inches wide, is placed over the laparotomy pads protect ing the small bowel and is held in place by an assistant.

With their meticulous a t tent ion to sur- gical principles, the authors admonish the reader to rentind the assistants that pull ing or tugging on the retractors should not be necessary and, if it is clone, the reason for it should be sought and corrected.

The first suture should be used to sup- port the loosely hanging medial edge of the lower angle of the peri toneal incision, to prevent it f rom failing posteriorly and obscuring the field of operation. T h e trans- verse bar of a Balfour retractor is an ideal place to which to anchor this "McNeaty stitch."

Now, and not unlit now, is attention directed to the involved segment of bowel. The sigmoid flexure is retracted to the right and an incision is made along the so-called white line. This represents the

LO\V ANTERIOR RESECTION OF THE RECTUM ~71

fusion fascia lateral to the sigmoid flexure, which is formed during the final stage of bowel rotation. It is an avascular plane which provides entrance to the retroperi- toneal area. The incision should be ex- tended cephalad sufficiently to mobilize the distal port ion of the descending colon.

"The left ureter is identified and, to facil- itate periodic inspection, a piece of mois- tened tape is looped around it. Both ends ot the tape should be brought out of the wound and attached so that they will always be in evidence and prevent inadvertent in- jury to the ureter. By inserting the hand posterior to the mesentery of the sigmoid tlexure, progress can be made, by blunt dissection, to the right side o{ the great vessels. An incision is made into the pos- terior peritoneum, which is "tissue thin," in the area to the right of the mesentery of the sigmoid flexure. This right-sided retroperitoneal incision is extended 3 to 4 cm. cephalad to the bifurcation of the aorta and to the point o~ origin of the inferior mesenteric artery. Unless there is a specific contraindication, such as ex- treme obesity, this vessel can be transected flush with the aorta. A No. 1 chromic catgut tie is used and is anchored in place by a 00 chromic catgut suture ligature. When deal- ing with rectal and sigmoidal cancer, the authors have encountered no reason to regret ligating the vessel at this level. It is highly desirable to remove as much as pos- sible of the mesentery and its lymphatic vessels. In fact, such high ligation often facilitates subsequent mobilization of the colon and anastomosis without tension. While the parts are adequately exposed, repair of the cephalad cut edge of the pos- terior peri toneum is begun, thus avoiding the need for exposing it again later in the procedure. Only the most cephaiad few centimeters require reapproximation at this

time. Attention is directed to freeing the rec-

tosigmoid and proximal portion of the

rectum. This can be accomplished by ex- tending the posterior peritoneal incisions lateral to the rectum and joining them in the rectovesical or recto-uterine sulcus. By gentle anterior traction on the rectum, the proper plane for blunt dissection is re- vealed just anterior to the sacrum, and usually the rectum can be easily freed pos- teriorly. To enter this plane, occasionally adventitious fascial bands must be severed. Dissection (sharp and blunt) as far away from the rectum as possible (as in ab- dominoperineal resection) is continued posteriorly, anteriorly and laterally to the rectum. Usually, little bleeding is encoun- tered.

If the tumor has not been palpable prior to this time, it should be possible to feel it now. The surgeon should be able to de- termine the level of the distal margin of the tumor anti decide whether an anterior resection or an abdominoperineal resection should be performed.

It has been the policy of the authors that 3 to 5 cm. of the rectum and pararectal tissue distal to the tumor must be readily removable if an anterior resection is to be performed. To accomplish this, it is often necessary to extend the posterior rectal dis- section to the tip o~ the coccyx. The lateral stalks are identified and severed against the pelvic wall. If feasible, the stalks are di- vided between ligatures, but it is not essen- tial. If necessary, dissection in men is carried down to the prostate.

Having provided sufficient mobilization of the rectum distal to the tumor, the mes- entery of the rectum, which should be en- cased posteriorly in a smooth, fascialike membrane, should be carefully transected. Usually, there is considerable fat posterior to the rectum and as much of it as possible shou!d be removed. "vghen the mesentery of the rectum has been transected, stay sutures are placed IateralIy in the pararectal tissues, distal to the level of intended transection, to support the rectum. Bleeding originating

' ~ ' 9 M A R I N O A N I ) M A R I N O • i) I - -

within the pelvis should be coutrolled by ligatures because after the anastomosis is completed, this may be difficult and even impossible. Several laparotomy pads are introduced posteriorly, laterally and an- teriorly to the rectum to absorb "spill." Should any occur, several thicknesses should be used so that those that are soiled can be removed.

Provision is made for disposal of con- taminated instruments. The rectum is oc- cluded, with long, right-angle, interlocking Best clamps, just proximal to the proposed site of transection. Should this 1)e impossi- ble, a tape may be substituted. An incision is then made in the anterior wall of the rectum so that the intact mucosa bulges through the severed layers of muscle. The mucosa is incised and immediately suction is employed to aspirate all rectal contents. When circular transection of the rectum is completed, the specimen is wrapped in a towel and delivered from the pelvis. Usu- ally bleeding from the distal margins of the incision is active and the vessels, which are situated in the submucosa, are grasped with mosquito clamps and tigated with 000 chromic catgut. After bleeding is controlled,

attention is directed to the proximal por- tion of the bowel. Selection of the site for

transection of this segment of the bowel is based on two important factors: first, the

area selected must be assured of a good

blood supply. (Usually, at this point, de- marcation of the devascularized portion of

the bowel is apparent, the source of the blood supply being the marginal artery of

Drummond which originates from the m i d

colic artery.) Second, provision must be made for the proximal segment of the bowel

to extend far enough into the pelvis to

pe~*mit anastomosis wi~b.ou~, tension. Whe~ necessary, additional length of bowel can

be provided by incising the peritoneum

tateral to the descending colon. Conceiwt-

bly, it might even be necessary to mobilize

the splenic flexure. This is a rare require- l n e n t .

"vVhen the site of transection has been determined, the mesentery is incised in a medial direction, ligating blood vessels as they are encountered. A single, straight clamp is applied obliquely and the bowel is transected just proximal to the clamp. Probably a few arterial bleeders will require clamping and ligating.

The anastomosis is then performed "in the usual fashion," using a double row of sutures. "Seromuscular, interrupted sutures of 000 silk or cotton are placed, beginning in the posterior wall of the proximal bowel and then in the posterior wall of the distal rectum." These sutures are placed first in the midline and then interrupted stttures are used laterally on both sides. Usually seven to nine sutures are placed and then the two ends of 1)owel are approxi- mated gently with the sutures. Ygith the exception o[ one suture placed centrally and two placed laterally, all are "cut just above the knot." A 000 suture of atraumatic chromic catgut is then started at fhe pos- terior midtine, incorporating the mucosa and muscularis mucosae of the two layers. This suture is continued along the posterior wall "in an over-and-over fashion" on one side of the anastomosis until the lateral seromuscular suture is reached. Another atraumatic suture is used on the other half of the posterior midline. The authors pre- fer to lock every stitch, or every other stitch, to prevent puckering o[ the suture line, be- ing careful to avoid "a turned-in cuff of bowel wall." Both chromic sutures are then continued anteriorly as a ConneI1 sutu:ce and tied to each other in the middle of the anterior wall of the anastomosed bowel. Care should be taken to see that ~he jtmc- tional area of the two sutures is inverted. If an atraumatic occluding clamp was used on the proximal bowel, it is removed. The sero- muscular layer of interrupted silk or cotton sutures is continued anteriorly. Several

LOW ANTERIOR RESECTION OF THE RECTUM 0973

appendices epiploicae are used to cover the line of anastomosis and are secured by the ends of the seromuscular sutures. All su- tures are cut "close to the knot ," the stay sutures are removed and the imnen th rough the anastomosis is tested with the t humb and forefinger.

T h e margins of the incision in the pos- terior pe r i t oneum are r eapp rox ima ted so that the anastomosis becomes extraperL toneal and retroperi toneal . N o dra in is used but, occasionally, 1,000,000 units of penici l l in solution is in t roduced into the pelvis. I n addit ion, 500 rag. of Ter ramy- cin® are adminis tered in t ravenously with each liter of fluid in t roduced into the veins dur ing operat ion. Rarely is b lood required.

T h e abdomen is closed in the usual man- ner with the except ion that in te r rnp ted su- tures of No. 32 stainless steel are in t roduced to reinforce the .posterior rectus sheath and to close the anter ior rectus sheath. Four " tension sutures" o1 No. 28 stainless steel are used to reinforce the wound. T h e au- thors have observed that this type of w o u n d closure has been responsible for min imiz ing w o u n d complicat ions.

Finally, the anal sphincter muscles are di- lated gent ly (not divulsed) with two fingers.

Postopera t ive M a n a g e m e n t

One g ram of Ter ramycin® is adminis- tered by infusion on each of the first three days after opera t ion and, after that, 1 Gm. of e ry thromycin is given orally on each of the four succeeding days. Small quant i t ies of water, tea and bro th are al lowed 48 hours after operat ion. A general fluid diet is per- mitred after gas has been passed f rom the rec tum and a soft diet is given after the first bowel movement . T h e Levin tube is removed when bowel sounds become audi- ble. A No. 22 or 24 rectal tube, marked with adhesive tape "4 or 5 cm. f rom its tip (Fig. 1), is inserted for 20 minutes every two hours, beg inn ing 24 hours after opera- tion, and is con t inued unti l flatus is ex-

•. ai

Fro. 1. Rectal tube. Note collar of adhesive tape to prevent insertion I I lOYC [ ] / a l l I t i l l .

pelled spontaneously. No rectal tentpera- tures are taken and digital examina t ion of the rectum is not permit ted. T h e first bowel movemen t occurs f rom the third to the seventh day after operat ion, and often it is preceded by :t slight discharge of bloody mncus. Frequent bowel movement s that of- ten are precipitous are not u n c o m m o n dur- ing the first few weeks, bu t in no instance has cont inence for feces or gas been im- paired.

R e s u l t s

Records of 40 consecutive pai tents with cancer of the rectum, s i tuated between 9 and 16 cm. f rom the anal verge, were studied. The i r ages varied !2rom 40 to more than 80 years. T h e ages of six were in the decade from 40 th rough 49 years; six were 50 th rough 59 years; 16 were 60 through 69; 10 were 70 th rough 79, and two were 80 years of age.

Most of the lesions were type B or C Dukes. Eight patients (20 per cent) had metastasis to the liver. Of the grades re- corded, nine lesions were Dukes, type A, 12 were type B ant! ! ! were type C.

Sixty-six per cent of the iesions were s i tuated between 9 and t3 cm. from the anal verge; 14 patients had lesions with lower margins 9 to 1! cm. f rom the anal verge. I n 11 pat ients the distance was I 1 to

374 MARINO AND M:\RINO

lqc.. 2. Distal end of lesion was 10 cm" fi'om aria! verge. Five cm. of rectum and pararectal tissue distal to lesion wcre removed. Note that there is at least 3 cm. of clearance, despite shortening of bowel which occurred after removal of t u m o r .

13 cm.; in n ine i t was 13 to 15 cm., and in six it was 15 to 16 cm. T h e l eng th of re- movab le bowel be tween the lower marg in of the t u m o r a n d the anal verge va r ied from 3 to 10 cm. I n six pa t i en t s the length was 3 to S.5 cm.; in one it was 4 cm.; in 11 it was 5 cm.; in 1 1 it was 6 to 6.5 cm.; in

seven it was 7 to 7.5 cm.; in two it was 8 cm., a n d in two it was 10 cm. (Fig. 2) .

R e t u r n of n o r m a l or nea r n o r m a l func-

t ion was slow. O n the average, gas was passed a b o u t three days af te r ope ra t i on and, as a rule , the first bowel m o v e m e n t

occurred a b o u t six days pos topera t ive ly . T h e first m o v e m e n t has been de layed as long as 11 days w i t h o u t a p p a r e n t i l l effect.

T h e r e was on ly one d e a t h r e l a t ed to the surgical p rocedure , and this was caused by

homologous se rum j a u n d i c e which a p - pea red three m o n t h s af ter o p e r a t i o n in a pa t i en t who r e q u i r e d b tood t ransfus ion

before ope ra t i on . Re la t ive ly m i n o r comp l i ca t i ons occur red

~: efgEt pa t ien t s . T h e y we~e m i l d throm- boph leb i t i s ; p s e u d o m e m b r a n o u s colitis,

which occur red two weeks pos tope ra t ive ly and r e q u i r e d r e h o s p i t a l i z a t i o n for five days; p e r ! a n a l ecchymosis t r ans i en t tachy-

card!a; ca rd iac d e c o m p e n s a t i o n occur red in

an 83-year-old, obese w o m a n on the th i rd day af ter ope ra t i on and, for a br ief per iod ,

she became a t roub lesome p r o b l e m of" elec- t ro lyte balance; one p a t i e n t had a throm-

bosed h e m o r r h o k t ; one h a d py rex ia of un-

known cause which r e s p o n d e d to symp- tomat ic t r ea tmen t ; and one p a t i e n t h a d an

acute ca ta ton ic s ch i zophren ic r eac t ion for 10 days af ter ope ra t ion , fo l lowed by com-

p le te recovery. T h e r e were no abscesses nor fecal leaks. N ine pa t ien t s in whom cura t ive opera-

t ions were a t t e m p t e d had lesions s i tua ted f rom 9 to I1 cm. from tim a n a l verge. F ive

had surv ived for per iods v a r y i n g from seven mon ths to six years. T h r e e d i e d of r ecu r r en t cancer and one (a l ready m e n t i o n e d ) d ied

o1~ homologous se rum j a u n d i c e . Five pa t ien t s wi th lesions at the 9- to- l l -

cm. level had pa l l i a t ive resec t ions and anas- tomosis, desp i te hepa t i c metastas is . One

d ied six mon ths af ter surgery , one was lost to fol low up b u t p r e sumed dead , and three d ied of cancer 12. 12 a n d 8 months , re- spectively, af ter ope ra t ion .

T h e r e were 11 pa t ien t s in the g roup wi th lesions s i t ua t ed be tween 11 and 13 cm. from the anal verge. Of these, n ine survived for per iods wtry ing f rom 15 m o n t h s to 71/~_ years. One d i ed of r e c u r r e nc e 12 mon ths af ter o p e r a t i o n and a n o t h e r d ied of gas- tric ca rc inoma 30 mon ths a f t e r opera t ion (at necropsy there was no ev idence of re- cur rence in the rectum).

T h e r e were seven p a t i e n t s wi th lesions be tween 13 a n d 15 cm. f rom the anal verge, a n d they have surv ived fo r per iods vary- ing f rom two m o n t h s to s ix years. T w o o the r pa t i en t s u n d e r w e n t pa l l i a t i ve pro- cedures a n d surv ived for one year each

w i t h o u t a cotostomy.

F ive patie:~ts wi th lesions sitv.ated !5 to

16 cm. f rom the ana l ve rge surv ived for per iods va ry ing f rom six m o n t h s to six

years. One p a t i e n t who u n d e r w e n t pal l ia-

t ive surgery e l u d e d fo l l ow-up efforts. T h e au tho r s conc lude this me t i cu lous

CONTRIBUTIONS OF WILLIAM ERNEST MILES 375

a n d e x h a u s t i v e s t u d y by a c k n o w l e d g i n g

t h a t w h a t t hey have presented is n o t n e w

a n d t h a t t h e i r s is a s m a l l b u t c a r e f u l l y

c o n t r o l l e d series. As a r e s u l t , h o w e v e r ,

t hey w e r e a b l e to r e a c h t h e i m p o r t a n t a n d

j u s t i f i a b l e c o n c l u s i o n s t h a t g o o d r e s u l t s c an

be o b t a i n e d by a n t e r i o r r e s e c t i o n a n d anas-

tomos is , a n d t h a t c o l o s t o m y c a n be o b v i a t e d

safe ly w h e n c a n c e r s a r e s i t u a t e d b e t w e e n 9

a n d 16 cm. f r o m t h e a n a l ve rge .

R e f e r e n c e s

1. Babcock: ()noted by Goligher, J. C. and E. S. R. Hughes: Sensibility of the rectum and colon: Its role in the mechanism of anal continence. Lancet. 1:543, 1951.

2. Bacon, H. E., S. T. Ross and P. M. Recio: Proctology. Philadclphia, J B. I~ippincott Company, 1956, p. 305.

3. Black, B. M.: Combined abdomino-endorectal resection: A surgical procedure preserving continuity of the bowel, for the management of certain types of carcinoma of the mid- rectum and upper part of the rectturl. Prnc. Statf Meet., Mayo Clin. 23:545, 1948.

I. Hochenegg: Quoted by Black, B. M.: Combined

abdomino-endorecta l resection: T e c h n i c a l as- pects and indications. A.M.A. Arch. Surg. 65: 406, 1952.

5. Kraske, P.: Zur exstirpation hochsitzendes Mast- darmkrehses. Vcrhandl. deutsch. Geselsch. C/fir. 29: 31, 1900.

6. Lisfranc, J.: Memoirc sur t'excision de la partie inferieure du rectum devenue carcinomateuse. Rev. todd. franc. 2: 380, 1826.

7. Maunsell: Quoted by Black, B. M.3 8. Mayo, C. H.: Evolution in the treatment of

cancer of the rectum. J.A.M,A. 4th 1127, 1903. 9. Mayo, C. W.: Anterior resection for carcinoma

of the lower portion of sigmoid, the recto- sigmoid and the upper portion of rectum: Present status. S. Clin. North America, Au- gust 1957, p. 981.

10. Miles, W. E.: A method of performing ab- dominoperineal excision for carcinoma of the rectum and the tcrmimtl portion of the pelvic colon, l.ancet. '2_: 1812, 1908.

11. Salvati, E. P.: Combined abdon~inoendorectal resection, l)is. Colon & Rectum. 4: 363, 1961.

12. f u r n b u l l , R. B. and .\. Cuthbertson: Ab- domino rectal pull-through rc.~ction for cancer and for Hirschsprung's disease: De- layed postmu)r colorectal anastomosis. Cleve- lau "~ Clin. Ouart. 28: 109, 1961.

Contr ibut ions of Wi l l iam Ernest Miles to Surgery of the R e c t u m for Cancer *

VICTOR A. GILBERTSEN,* * ~I .D.

From the University of Minnesota, Minl~eapolis, Mit~e,~ota

T H E AUTHOR i n t r o d u c e s t h e r e a d e r to

th i s f a s c i n a t i n g r e c i t a l of e v e n t s p e r t a i n i n g

to t h e t i fe of W i l l i a m E r n e s t M i l e s a n d

s o m e l i t t l e k n o w n fac t s c o n c e r n i n g t h e

h i s t o r y of m a n a g e m e n t of c a n c e r of t h e

Abridgme~qt of origh-..ai article read a~ the .join~ meeting of the American Proctologic Society and the Section of ProctoloT/ of the Royal Society of Medicine, Philadelphia, Pennsylvania, M'ay 9 to 14, 1964.

** Assistant Professor, Surgery. Supported in part by the Andrew Dewing Memo-

rial Fund.

r e c t u m w i t h t h e f o l l o w i n g o b s e r v a t i o n :

" A l t h o u g h \ ,V i l l i am E r n e s t M i l e s was n o t

t h e first to exc i se a c a n c e r of t h e r e c t u m , "

h e w r o t e , " n o r e v e n t he first to d o so by

t h e c o m b i n e d a p p r o a c h , t h e f o r m u l a t i o n of

h is o p e r a t i o n r e p r e s e n t s w h a t a p p e a r s to

h a v e b e e n the b e g i n n i n g of a r a d i c a l c h a n g e

in p h i i o s o p h y o~ a p p r o a c h to t r e a t m e n t of

t h i s d i sease . " T h u s , h e s o u n d e d t h e key-

n o t e - - t h e e n t i r e s i g n i f i c a n c e of M i l e s '

c o n t r i b u t i o n to s u r g e r y of c a n c e r of t h e

r e c t u m .