The use of posterior trans-sphincteric approach in surgery of the rectum: a Chinese 16-year experience

Abstract

Background: The posterior trans-sphincteric approach to treat different lesions of the rectum has been known since the last century. Although there are many advantages to this procedure, it has never been widely accepted because many surgeons fear its potential postoperative complications. The purpose of this study is to reevaluate the role of this conventional approach to surgery of the rectum from the authors' 16 years experience.

Methods: Data were collected retrospectively from clinical records of 102 patients with mid- to low-lying rectal neoplastic disease treated by a single surgeon using a posterior trans-sphincteric approach to the rectum at Peking Union Medical College Hospital, China, between August 1990 and August 2006. The Williams incontinence scale of every patient was assessed preoperatively and postoperatively and the results were analyzed.

Results: Forty men and 62 women with a median age of 55.5 years (range = 21-87 years) underwent this approach. Their preoperative anal continence was assessed as grade 1 in 98 and grade 2 in 4. Indications for surgery were rectal villous adenoma in 36, early rectal carcinoma in 43, advanced rectal carcinoma in 10, and rectal submucosal neoplastic disease in 13. The median operating time, blood loss, and postoperative hospital stay were 75 min (range = 40-180 min), 60 ml (range = 0-300 ml), and 8 days (range = 7-60 days), respectively. All 102 rectal neoplastic diseases achieved complete excision (partial rectectomy in 96, segmental rectectomy in 6), and the resection margins were all clear. Three patients (2.9%) developed postoperative wound infection, and 4 patients (3.9%) developed fecal fistula. Thirty-three patients (32.4%) developed postoperative initial incontinence to flatus (n = 26) or liquid stool (n = 7) within 1 week. Three months after the operation, 94 patients (92.2%) achieved grade 1 continence and only 8 patients (7.8%) had occasional episodes of flatus incontinence. No patient developed postoperative anal stricture. There was no operation-related mortality. Three patients (2.9%) developed local tumor recurrence during median follow-up of 76.8 months (range = 10-192 months).

Conclusion: The posterior trans-sphincteric approach is suitable for mid- to low-lying rectal lesions amenable to treatment using local therapy.