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A retrospective study was made to compare the results of restorative surgery with those of total rectal excision in the treatment of patients with a poorly differentiated adenocarcinoma of the middle third of the rectum (between 8 and 12 cm from the anal verge). Of 1163 patients presenting between 1963 and 1975, 42 with poorly differentiated tumours at this level were followed up after treatment by a radical (i.e. curative) operation. Twenty-eight underwent total rectal excision and 14 anterior resection. Examination of the preoperative biopsy correctly established the histological grade in 17 (40 per cent) of 42 cases. Pathological examination of the resected specimens showed a slightly higher proportion of Dukes' C2 tumours and those with venous invasion removed by total rectal excision, but the extent of local spread among tumours removed by either operation was similar. There was no operative mortality. Ten out of 28 patients treated by total rectal excision (36 per cent) and 6 out of 14 treated by anterior resection (43 per cent) were alive at 5 years. One patient developed a histologically proved local recurrence after anterior resection; no other proved local recurrence was recorded. It would appear, therefore, that where radical surgery is possible, anterior resection offers as good a prospect of cure as total rectal excision for poorly differentiated tumours of the mid-rectum.

Abdominoperineal excision of the rectum remains the accepted treatment for the majority of lower rectal adenocarcinomas. Despite advances in surgery and anaesthesia, survival has not improved over the last 40 years. Over a 12-year period the overall 5-year survival rate for patients undergoing abdominoperineal excision for adenocarcinoma of the rectum at Groote Schuur Hospital, Cape Town, was 39%. The incidence of complications associated with the operation remains high (36%). The major causes of morbidity still originate in the urinary tract and the perineal wound. Further techniques which may improve the overall survival are briefly reviewed.