Surgery is the most important form of treatment for rectal cancer by radical local tumour control. Despite that recurrence-free survival is still the major goal of surgical therapy, it is also widely accepted that the surgeon should relieve distressing symptoms associated with the procedure.
A major concern of patients with colorectal cancer is the possibility that surgery leads to a permanent stoma. In the ‘early days’ of rectal surgery, abdominoperineal resection (APR) of the rectum with construction of a permanent colo- stomy was the treatment of choice for patients with cancer located in the middle or lower third of the rectum. Intramural spread of cancer and the possibility of lymphogenic spread via the aboral route were major concerns and led to the recommendation of a safety distance of at least 5 cm from the distal tumour margin to prevent local recurrence.
As a result of more recent studies, it is now widely accepted that intramural spread rarely exceeds 1 cm and that patients in whom an intramural spread wider than 1 cm is observed are usually diagnosed in a more advanced tumour stage, including the lymph node metastases stage. This knowledge, as well as the knowledge that the lymphogenic spread of rectal cancer has a cephalad direction and occurs along the mesorectum to the inferior mesenteric artery, have led to a change in the surgical approach for local control of rectal cancer.
Complete excision of the mesorectum and a distal tumour-free margin of 2 cm are the essential criteria for minimizing the risk of local recurrence.
Removal of the sphincter apparatus does not substantially increase the radicality of the surgery, provided that the sphincter is not infiltrated by the tumour. Is sphincter-saving surgery, therefore, less radical than APR?
Several studies have demonstrated that sphincter-saving surgery does not impair radicality. The local recurrence rate, which is the best parameter to evaluate the efficacy of local tumour control, has been shown to be similar in comparable groups treated by APR or sphincter preservation.
Although the above-mentioned changes as well as the progress in surgical techniques have reduced the amount of rectal cancer patients needing a permanent stoma to about 20% in specialized centres, this rate is considerably higher, up to 40% to 50%, in less specialized surgical departments.
Figure 1) Surgery of rectal cancer. Resection and reconstruction according to the localization of tumour. A Anterior resection with hand-sewn or stapled anastomosis. B ‘Ultralow’ resection with coloanal anastomosis. C ‘Ultralow’, intersphincteric resection with coloanal anastomosis. D Abdominoperineal resection with sphincter replacement by dynamic graciloplasty
The surgical techniques available to restore continuity depend on the level of dissection of the rectum. In cases where the rectal stump is of sufficient length, the descending colon is anastomosed by hand or by the more popular stapling gun (Figure 1). This is the most common sphincter- saving method and is the classical ‘anterior resection’.
Complete excision of the rectum down to the level of the levator ani requires an anastomosis with the anal canal – a ‘coloanal anastomosis’.
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The principles of this technique were described in 1888 by Hochenegg, who advocated a sacral approach to the rectum. Later, pullthrough procedures via an abdominal route, with or without eversion of the anorectal stump, were reported by others. However, due to the technical difficulties and the high morbidity associated with these procedures, APR was regarded as the method of choice until the modern technique of transanal resection and coloanal anastomosis was presented by Parks in 1972.