Advances in rectal cancer surgery

The incidence of lateral pelvic side-wall nodal involvement in low rectal cancer may be similar in Japan and the West

BACKGROUND

There is an East-West divide with regard to the frequency, significance and management of lateral pelvic side-wall nodes associated with low rectal cancer. In Japan, removal of nodes is considered essential in curative treatment of selected patients. In the West, involved nodes are generally considered as metastatic disease. There may be international differences in rectal cancer behaviour.

METHODS

A review of relevant studies was undertaken using PubMed, Cochrane Library and personal archives of references; further cross-referencing was conducted. Historical developments, relevant anatomy and reports on lateral pelvic lymphadenectomy (LPLD) were identified. Outcomes following LPLD were assessed.

RESULTS

The low rectum has lateral lymphatic drainage. Enhanced pelvic imaging techniques suggest that some patients with low rectal cancer have lateral pelvic lymph node involvement. However, there is no universal agreement on the definition of either the rectum or low rectal cancer. Selective use of LPLD has led to good outcomes in Japan. An alternative strategy might be neoadjuvant therapy for involved lateral nodes.

CONCLUSION

Pelvic imaging and correlation with pathological findings are crucial in the assessment of lateral pelvic side-wall nodes. East and West should combine their experience of preoperative staging, surgical treatment and pathological assessment of low rectal cancer.

Evaluation of anal function after surgery for rectal cancer

BACKGROUND AND OBJECTIVES

Sphincter-saving surgical procedures for rectal cancer have been legitimized if executed respecting the criteria of oncological radicalness. Our objective was to evaluate anal sphincteric continence after rectal cancer surgery.

METHODS

A detailed questionnaire regarding continence was administered to 3 groups of patients. Group 1 was composed of 9 patients treated with a higher (>4 cm), stapled colorectal anastomosis; the 9 group 2 patients were treated with a low (< or =4 cm), stapled colorectal anastomosis; the 9 group 3 patients underwent coloanal anastomosis.

RESULTS

The results were evaluated about 3 years after surgery. Continence was excellent in group 1 and very good in group 2. However, in group 3, we observed diminished gas/feces discrimination, reduced ability to postpone evacuation, and increased soiling and perianal rash.

CONCLUSIONS

Anal sphincteric continence was better after surgery with a high or low colorectal anastomosis than after coloanal anastomosis.

Mesorectal excision for rectal cancer: a view from Europe

The local recurrence rate after rectal cancer surgery is discussed as related to conventional and total mesorectal excision (TME) techniques. Studies now show that the wide variation in results between centers and among surgeons depends, at least in part, on differences in surgical technique. We conclude that local tumor recurrence rate is lower after TME than after conventional surgery and emphasize the importance of a standardized macroscopic evaluation of the resected specimen. Population-based registration to evaluate the quality of surgery is recommended. It is also suggested that randomized studies on adjuvant treatment for rectal cancer should include a "surgery only" arm when a local tumor recurrence rate of 10% or less is being studied. Until such investigations are performed, we conclude that the role for adjuvant treatment is questionable and that TME surgery is preferred as the treatment option for Stage T1-T3 rectal cancers.

Evaluation of a policy of total mesorectal excision for rectal and rectosigmoid cancers

BACKGROUND

Total mesorectal excision (TME) is advocated for rectal cancer but the indications and extent of resection vary widely between surgeons.

METHODS

Seventy-six consecutive patients (61 elective, 15 acute admission) with rectal or rectosigmoid cancer were admitted to a unit where TME was the preferred surgical option for potentially curative cancer at all levels of the rectum.

RESULTS

Procedures undertaken were anterior resection (38 patients), abdominoperineal resection (18), Hartmann's procedure (ten) and transanal excision (one). Six patients had proximal faecal diversion alone and surgery was withheld in three. Anastomotic leaks occurred in six of 37 patients who had anterior resection with primary anastomosis, resulting in one early death. The presence of a proximal stoma did not influence the rate or seriousness of anastomotic dehiscence. After potentially curative TME in 45 patients, there have been eight local recurrences, four associated with systemic metastases and four which occurred in isolation (median follow-up 34 months).

CONCLUSION

Curative TME was deemed appropriate in 59 per cent of unselected patients with rectal cancer. It was associated with few local recurrences but a morbidity rate that questions its role in treatment of upper third tumours.