[Total excision of the mesorectum in cancer of the lower and middle rectum. Oncological and functional results].

INTRODUCTION: The introduction of total mesorectal excision (TME) in the treatment of rectal cancer has improved survival rates and decreased recurrence. Our objective was to analyse perioperative data as well as the results of the follow-up examination. Risk-factors for local recurrence should be identified since the indication for adjuvant therapy in "optimal surgery" has to be redefined.

PATIENTS AND METHODS: Between March 1997 and December 2001, 108 patients with adenocarcinoma of the lower and middle rectum were operated on by three surgeons according to the concept of total mesorectal excision. In 75 (69.4%) patients,a lower anterior resection and in 32 (29.2%) cases an abdominoperineal resection was performed. One patient received a Hartmann's resection. There were 15 cases of stage IV (UICC) present and in 53 patients the tumor extension was restricted to the wall. Demographic and perioperative data as well as the results of the follow-up examination were registered prospectively. The median follow-up period amounted to 24 months (2-56).

RESULTS: A total of 87 patients underwent a curative resection. Fourteen lymph nodes were dissected (median). Pelvic autonomic nerve preservation was possible in 90 patients. The median intraoperative blood loss was 500 ml. As surgical complications, anastomotic leakage occurred in 18% of cases, perineal wound infection in 33%, and bladder dysfunction (requiring catheterisation) in 5.6%. The overall rate of recurrence was 17.5%. The rate of local recurrence was 4.9% and the survival rate was 91% over 3 years. Risk factors for local recurrence are N2-disease, transmural growth and tumor localisation in the lower third of the rectum.

CONCLUSIONS: TME offers good oncological and functional results with low complication rates for the treatment of cancer in the middle and upper third of the rectum. Interdisciplinary multicenter studies are still necessary to redefine the place of adjuvant radiation and chemotherapy in cases of cancer in the lower two thirds of the rectum and stage III disease.