ObjectiveTo evaluate the complications and oncologic and functional results of preoperative radiochemotherapy and sphincter-saving resection for T3 cancers of the lower third of the rectum. Summary Background DataCarcinomas of the lower third of the rectum (i.e., located at or below 6 cm from the anal verge) are usually treated by abdominoperineal resection, especially for T3 lesions. Few data are available evaluating concomitant chemotherapy with preoperative radiotherapy for increasing sphincter-saving resection in low rectal cancer. MethodsBetween 1995 and 1999, 43 patients underwent preoperative radiochemotherapy with conservative surgery for a low rectal tumor located a mean of 4.5 cm from the anal verge (range 2-6); 70% of the lesions were less than 2 cm from the anal sphincter. There were 40 T3 and 3 T4 tumors. Patients received preoperative radiotherapy with a mean dose of 50 Gy (range 40 -54) and concomitant chemotherapy with 5-FU in continuous infusion (n ϭ 36) or bolus (n ϭ 7). Sphinctersaving resection was performed 6 weeks after treatment, in 25 patients by using intersphincteric resection. Coloanal anastomoses were associated with a colonic pouch in 86% of the patients, and all patients had a protecting stoma. ResultsThere were no deaths related to preoperative radiochemotherapy and surgery. Acute toxicity was mainly due to diarrhea, with 54% of grade 1 to 2. Four anastomotic fistulas and two pelvic hematomas occurred; all patients but one had closure of the stoma. Distal and radial surgical margins were respectively 23 Ϯ 8 mm (range 10 -40) and 8 Ϯ 4 mm (range 1-20) and were negative in 98% of the patients. Downstaging (pT0 -2N0) was observed in 42% of the patients (18/43) and was associated with a greater radial margin (10 vs. 6 mm; P ϭ .02). After a median follow-up of 30 months, the rate of local recurrence was 2% (1/43), and four patients had distal metastases. Overall and disease-free survival rates were both 85% at 3 years. Functional results were good (Kirwan continence I, II) in 79% of the available patients (n ϭ 37). They were slightly altered by intersphincteric resection (57 vs. 75% of perfect continence; NS) but were significantly improved by a colonic pouch (74 vs. 16%; P ϭ .01). ConclusionsThese results suggest that preoperative radiochemotherapy allowed sphincter-saving resection to be performed with good local control and good functional results in patients with T3 low rectal cancers that would have required abdominoperineal resection in most instances.Carcinomas of the rectum infiltrating the muscular layer and the perirectal adipose tissue and located in the lower third of the rectum (i.e., T3 tumors within 6 cm of the anal verge [or anal margin]) are traditionally treated by abdominoperineal resection (APR). Indeed, local excision and sphincter-saving resection (SSR) are proposed only in patients with well-differentiated T1-T2 disease. For T3 disease, APR is justified by the difficulties of achieving radial and distal negative margins because of the narrow shape of the distal pe...

These preliminary results suggest that intersphincteric resection can be an alternative to abdominoperineal resection for selected rectal tumors situated at the anorectal junction, without compromising chance of cure. Functional results and continence were not altered by subtotal resection of the internal anal sphincter.

Background. Thrombosis of the central veins is one of the most frequent complications of implanted venous access devices. Among the first cases occurring in our patients, most were associated with left‐sided placement of the ports, with catheter tips lying against the external wall in the upper half of the superior vena cava. Some chest radiographs showed lateromediastinal opacities centered on the catheter tip, suggesting a vessel injury. This position allows a narrow contact between the catheter tip and the vessel wall, thus endothelial injuries might result from mechanical and chemical attack. Methods. To assess the role of catheter position, we reviewed the routine chest radiographs of 379 patients who received chemotherapy through venous access devices and were followed up at our department between December 1985 and December 1990. Four groups (upper left, upper right, lower left, and lower right) were defined according to the level of the catheter tip (innominate veins or upper half of the vena cava versus lower half of the vena cava or auricula) and to the side of port implantation. Results. Ten patients developed symptomatic venous thrombosis (superior vena cava in 9 patient, left subclavian vein in 1 patient). A strong correlation existed between catheter position and incidence of thrombosis: upper left, 8/28 (28.6%); upper right, 1/33 (3%); lower right, 1/68 (1.5%); and lower left, 0/250. Since 1988, we have insisted on replacement of malpositioned catheters, and we have observed fewer thromboses (2/191 versus 8/188). Conclusions. The current study suggests that patients with left‐sided ports and catheter tips lying in the upper part of the vena cava are at high risk for severe thrombotic complications.

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The double dynamic graciloplasty is associated with a high risk of neosphincter stenosis, which may entail morbidity, reintervention and poor functional results. The stenosis is a heterogeneous feature of the neosphincter induced by asymmetrical traction of both gracilis muscles. It is suggested that single dynamic graciloplasty should be used for anorectal reconstruction after APR. Presented to the 101st congress of the Association Française de Chirurgie in Paris, France, October 1999, and to the European Council of Coloproctology in Munich, Germany, October-November 1999

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