Assessment of quality of life in surgery

Abstract

We share Mr Meyrick Thomas's concern regarding the terminology of what is low or high in anterior resection.He is right to infer that total mesorectal clearance was carried out in our patients as described by Heald et a / .We d o not understand his concern regarding the 74:40 ratio of1ow:high anastomosis, as these ratios are similar to those in other reports.Total mesorectal clearance does not necessarily mean a coloanal anastomosis as reflected in Heald's own data, in which at least 16 per cent of anastomoses are > 6 cm from the anal verge'.Others using this technique have reported up to 50 per cent of tumours > 8 cm from the anal verge2.Confusion in this area remains because some series, as referred to above, report on either tumour or anastomotic height; these parameters themselves vary depending on digital or flexible or rigid sigmoidoscopic examination.Lack of uniformity in this area makes comparisons between series difficult.For this reason our definition is derived from Turnbull er u/.3, who defined high or low based on whether the anastomosis was above or below the peritoneal reflection; this overcomes any arbitrary division of the rectum and is anatomically objective.We are presently examining tumour and anastomotic heights, degree of mobilization and clearance rates in an attempt to clarify this issue.Mr Cunliffe refers to our low abdominoperineal resection ( A P R ) rate of 14.7 per cent.Even with the addition of the six permanent stomas following anastomotic dehiscence this gives an overall permanent stoma rate of 18.9 per cent, which is comparable to results of others'.Furthermore.this assumes a 100 per cent closure rate tor those who d o advocate a defunctioning colostomy in addition to the permanent colostomies resulting from leaks in these series.We disagree that a defunctioning stoma, either colostomy or ileostomy, will allow the conservative management of a significant anastomotic dehiscence.Anastomotic dehiscence, sepsis and resultant death have been reported in patients with defunctioning stomas after colorectal anastomosis'.Furthermore, the value of a defunctioning ileostomy in itself might be disputed because of the significant morbidity, reported by us4 and others5, in the closure of defunctioning ileostomies associated with restorative proctocolectomy.There is no reason to believe that ileostomy closure after anterior resection would have any lesser morbidity.Messrs Karanjia and Heald comment on our term 'wide excision of the mesorectum'.Although the terminology may be different, this does, we believe, correspond to their 'total mesorectal excision'.The discussion of whether the Basingstoke anterior resection and the APR patients constitute a consecutive series refers to the fact that the quoted paper does not contain information from both groups, so it is unclear whether these consecutive series are contemporary.We found it interesting that the clinical leak rate was not reported in the Basingstoke series despite the obvious association between anastomotic dehiscence, peritonitis and septicaemia.The similar leak rate between the two series again strengthens our contention that a defunctioning colostomy may be unnecessary at anterior resection.The final point raised by Karanjia and Heald relates to the relative risks of not defunctioning the low anastomosis and the resultant potential complications against the relative risks of colostomy formation and closure.While there was no death from closure of colostomy in their series this is not always the case'; furthermore they neglect to highlight the very significant morbidity associated with this procedure demonstrated in their own results'.

Keywords

Affiliated Institutions

• Royal College of Surgeons in Ireland IE
• Royal Glamorgan Hospital GB

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