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Surgical Treatment of Rectal Cancer: Radical Resection
Surg Oncol Clin N Am 15 (2006) 95–107
Surgical Treatment of Rectal Cancer: Radical Resection Seung-Yong Jeong, MD, PhDa, David B. Chessin, MDa, Jose G. Guillem, MD, MPHa,b,* a
Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-1077, New York, NY 10021, USA b Cornell University Medical College, 520 East 70th Street, New York, NY 10021, USA
Total mesorectal excision (TME), introduced and popularized by Heald and colleagues [1] in the early 1980s, is the operative technique of sharp rectal mobilization along the avascular plane between the visceral fascia of the mesorectum and the parietal fascia of the pelvic side wall. The mesorectum is defined as the fatty lymphovascular tissue that surrounds the rectum. Although there are benefits to TME, such as preserving the pelvic autonomic nerves and increasing the anal sphincter preservation rate, the most important effect of TME is its improvement in local control of the disease [2,3]. This is clinically important because local failure is associated with decreased survival and the agonizing symptoms of intractable pain, bleeding, and voiding and defecation problems. Although there is a wide variability in the reported local recurrence rate after rectal cancer surgery, it may range from 35% to 45% in patients treated with conventional rectal resection. However, studies of radical rectal resection using the TME technique have reported local recurrence rates ranging from 3% to 11% [4].
Oncologic considerations Total mesorectal excision (TME) Studies that examined the mesorectum of resected upper rectal cancer have revealed that lymph node metastasis in the mesorectum are rarely * Corresponding author. Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-1077, New York, NY 10021. E-mail address: [email protected] (J.G. Guillem). 1055-3207/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.soc.2005.08.007 surgonc.theclinics.com
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beyond 5 cm distal to the mucosal edge of the tumor [1,5,6]. In addition, mesorectal excision beyond 5 cm distal to the tumor may result in an increased risk of anastomotic leakage without any oncologic benefit [7]. Therefore, a partial mesorectal excision with a distal 5-cm resection margin is likely sufficient for upper rectal cancer. The effect of TME on local control has been shown to be further enhanced by adding preoperative radiation therapy (RT). A prospective, randomized trial conducted by Sauer and colleagues for the German Rectal Cancer Study Group [8] compared a protocol consisting of preoperative chemoradiation therapy (5040 cGy plus a continuous intravenous infusion of fluorouracil) followed by TME, with TME followed by postoperative chemoradiation therapy. The 5-year local recurrence rate was significantly lower in the group treated preoperatively with chemoradiation, although the 5-year overall survival rates were not different between the two groups. Another prospective, randomized trial by Kapiteijn and colleagues for the Dutch Colorectal Cancer Group [9] compared preoperative short-course radiation therapy (500 cGy on each of 5 days) followed by TME (RT plus TME) with TME alone. The 2-year local recurrence rates were significantly lower in the RT-plus-TME group (2.4%) than in the TME-alone group (8.2%), but 2-year overall survival and distant recurrence rates were not different between the two groups. Therefore, it appears that neoadjuvant therapy followed by TME provides for further improvement in local recurrence rates. Distal resection margin Classically, the recommended distal resection margin for rectal cancer resection was 2 cm or greater [10]. However, several studies have shown that distal intramural spread of tumor rarely exceeds 2 cm, and local control and survival may not be compromised by shorter distal margins [11–14]. In addition, although in rare cases distal spread is found beyond 1 to 2 cm, it is often associated with tumors of advanced stage or unfavorable histologic features, and the poor prognosis in these patients is not improved by a resection margin longer than 2 cm [15]. Therefore, for tumors of the distal rectum, a 1-cm distal margin may be acceptable [14,16]. In addition, the present authors recently reported that a negative distal margin of less than 1 cm does not seem to compromise oncologic outcome when patients are treated preoperatively with combined modality therapy (CMT) and TME [17]. Circumferential resection margin The importance of the circumferential resection margin (CRM) was highlighted by Quirke and colleagues [18], who reported that a positive CRM in rectal cancer is associated with significantly worse local control. This finding was supported by a recent series reporting that a CRM of less than 2 mm was associated with a significant increase in local recurrence (16.0% versus
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5.8%, respectively, P % .0001) in 656 patients who had rectal cancer treated with TME [19]. Adjuvant radiation therapy has been given to reduce local recurrence when a negative CRM cannot be obtained. However, some data have suggested that it does not compensate for a positive CRM [20]. The present authors currently recommend resection of rectal cancer according to the principles of TME, with all efforts made to obtain a negative CRM, including en bloc resection of contiguous structures when it is clinically indicated. Level of vascular ligation Historically, some investigators have recommended ligation of the inferior mesenteric artery (IMA) at its origin (high ligation) [21]; however, there has been no prospective study that directly compared the outcome between the use of high ligation with low ligation in rectal cancer patients. However, for patients who have distal colon cancers, a French multicenter, prospective, randomized trial by Rouffet and colleagues [22], who compared left colectomy and high ligation of IMA with segmental colectomy and ligation of the primary feeding vessels, has shown no significant difference in longterm survival between the two groups. A potential risk of high ligation of the IMA includes injury to the hypogastric plexus near the posterior aspect of superior rectal artery, where it lies immediately anterior to the aorta. Currently, the recommended level of proximal vascular ligation for rectal cancer is at the origin of the superior rectal artery, which is immediately distal to the takeoff of the left colic artery [10]. However, for ultradistal colorectal or coloanal anastomosis, in which a full splenic flexure mobilization is required, a high ligation may be necessary to facilitate sacralization of the neorectum and a tension-free anastomosis. No-touch isolation technique The no-touch technique is a procedure composed of initial ligation of the lymphovascular pedicle of the tumor and subsequent proximal and distal luminal blockade with ligature or clamping before manipulation of the tumor mass. Since Turnbull and colleagues [23] reported an improved 5-year survival in patients in whom the no-touch isolation technique was applied, this procedure became regarded as a potentially useful technique. The survival benefit of this technique is hypothesized to be the result of limiting the influx of tumor cells into circulation during resection. However, the only prospective, randomized trial that compared the effect of the no-touch isolation technique with conventional colon cancer resection demonstrated no significant difference in 5-year survival between the groups [24]. Currently, a rectal cancer resection begins with mobilization of the sigmoid colon from its lateral location by incising congenital adhesions and the white line of Toldt. Following this procedure, the left ureter is identified
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proximally and displaced laterally. Proximal vascular ligation is then accomplished before rectal mobilization. Rectal washout Viable tumor cells in washing samples from the rectal resection margin, rectal stump, and circular stapling device have been reported [25,26]. Cells from these washings may be proliferative and have metastatic potential. Some authors suggest that preresection rectal washout with a cytocidal solution may improve local control and oncologic outcome [27]. However, a recent retrospective study that compared patients who had rectal cancer treated with rectal washout using a cytocidal drug followed by resection, and a control group treated with no washout and resection, did not demonstrate a difference in local recurrence between the groups [28]. Although there is no conclusive evidence that supports rectal washout, it has very low risk, minimal cost, and potential benefit and thus may be applicable during rectal cancer surgery [10]. Lateral node dissection For low rectal cancers, lymphatic spread occurs not only upward to mesenteric nodes along the superior rectal and inferior mesenteric vessels but also laterally to the hypogastric, obturator, and presacral lymph nodes along the middle rectal, sacral, and iliac vessels. Lateral lymph node metastases have been reported in up to 13% of rectal cancers located below the peritoneal reflection and as high as 25% in Dukes’ stage C rectal cancer [29]. The local failure rate is high, and the long-term prognosis is dismal in patients who have positive lateral lymph nodes, even compared with patients who have positive mesorectal lymph nodes [30]. Several retrospective studies from Japan have reported improved local control and survival when extended lateral lymph node dissection is performed. The authors recommend this procedure in patients who have low-lying rectal cancer invading the muscularis propria or deeper [31]. However, before routinely applying lateral lymph node dissection in clinical practice, it is necessary to determine whether the involvement of lateral lymph nodes is solely an indicator of advanced, incurable disease or whether the identification of positive lateral lymph nodes and lymphadenectomy provide for improved oncologic outcome. To date, no well-controlled prospective trial has demonstrated a benefit of lateral lymph node dissection on oncologic outcome. Moreover, this procedure has been associated with considerable impairment of genitourinary function. Currently, there is insufficient evidence to recommend a routine lateral lymph node dissection for patients who have distal rectal cancer. However, it may be performed when lateral lymph node metastasis is suspected by preoperative imaging studies or intraoperative findings, and when it is technically feasible.
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Recently, preoperative radiation therapy has been suggested as an alternative modality to lateral lymph node dissection in locally advanced rectal cancer [32]. A randomized, controlled trial of 51 patients who had locally advanced rectal cancer treated with preoperative radiation therapy has demonstrated no difference in survival and recurrence between patients treated with lateral lymph node dissection and those without. Future research efforts should focus on determining whether select subgroups of patients may benefit from extended lateral lymph node dissection. Sentinel lymph node mapping Lymph node metastases are the best predictor of survival in patients who have rectal cancer. Currently, there are no reliable methods that can determine precisely the lymph node status pre- or intraoperatively. However, some authors suggest that sentinel lymph node mapping may be an acceptable means of intraoperative determination of lymph node status in rectal cancer patients [33,34]. The sentinel lymph node mapping technique has been applied to colorectal cancer and found to be feasible, but concerns over accuracy and high false-negative rates have restricted its routine use in the clinical setting [33–36]. Moreover, it is less accurate in patients who received preoperative chemoradiation, likely because of its impact on lymphatic flow to and from the tumor [37]. Currently, sentinel lymph node mapping has a limited role in the management of rectal cancer. However, it may be worth studying in selected settings, such as in determining the value of extended lateral lymph node dissection for patients who have distal rectal cancer [38]. Extended resection: posterior vaginectomy, pelvic exenteration, and sacrectomy Direct tumor invasion into adjacent organs or structures is encountered in 6% to 10% of patients who have rectal cancer [39,40]. Contiguous tumor spread most commonly involves the uterus, adnexa, and posterior vaginal wall in females and seminal vesicles, prostate, and bladder in males. En bloc resection of the tumor with involved adjacent tissue should be performed whenever possible because it is associated with lower local recurrence and improved cancer-related survival [41,42]. A major consideration for the surgeon is that often it cannot be accurately determined whether the involvement of contiguous organs is the result of an inflammatory process or of malignant invasion. In this situation, the surgeon should proceed with en bloc resection when technically feasible [10]. The urinary bladder is the organ most frequently involved by locally advanced rectal cancer, and extended resection may include a partial or a total cystectomy [43,44]. Although morbidity rates may be increased following
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bladder resection, urinary diversion, or bladder repair, these procedures may prolong survival when resection margins are negative [45]. In female patients, the rectum and vagina lie in close proximity and have a communicating lymphatic system [46]. Therefore, local recurrence may be found in the posterior vaginal wall after rectal cancer resection. A review of 64 patients who required a partial vaginectomy while undergoing resection for primary rectal cancer documented a 46% 5-year overall survival and 16% local failure rate [47]. Local recurrence was more commonly found in patients who have positive surgical margins. Therefore, a partial vaginectomy is indicated for locally advanced rectal cancers involving the vagina, and may result in an improved long-term oncologic outcome [47]. More extensive surgery, such as total pelvic exenteration, with or without sacral resection, is more commonly used for recurrent cancer, but it may be indicated for selected primary rectal cancers [48]. Although the associated morbidity is high, careful patient selection may result in tolerable functional outcome and prolonged survival following these aggressive procedures [40,48,49].
Functional and technical considerations Autonomic nerve preservation and urinary and sexual function The pelvic sympathetic nerves originate from the splanchnic branches of T12 to L2, forming the preaortic superior hypogastric plexus [50]. The superior hypogastric plexus extends from an area just distal to the aortic bifurcation to the sacral promontory and then gives rise to the right and left hypogastric nerves (Fig. 1). The hypogastric nerves lie in the areolar tissue plane between the visceral fascia of the mesorectum and the parietal fascia covering the pelvic sidewall. The plane between the visceral and parietal fascia is very thin at the level of the pelvic brim, and the pelvic autonomic nerves are especially vulnerable to injury at this location during dissection. Injury to the hypogastric nerves results in increased bladder tone with reduced bladder capacity, voiding difficulty, impaired (retrograde) ejaculation in men, and the loss of vaginal lubrication and dyspareunia in women [4,50]. The parasympathetic nerves of the pelvis (nervi erigentes) arise from the S2–4 anterior spinal nerve roots and join the hypogastric nerves on the pelvic sidewall to form the inferior hypogastric plexus (see Fig. 1) [50]. Damage to the parasympathetic nerves leads to erectile dysfunction, impaired vaginal lubrication, and voiding difficulty [51]. Truncal autonomic nerve preservation (ANP) is defined as preservation of the anterior nerve roots of S2–4 and the superior hypogastric plexus [52]. With careful ANP, postoperative genitourinary and sexual dysfunction can be reduced from 25% to 75% with conventional resection to as low as 10% to 28% [53]. More specifically, the incidence of neurogenic bladder can
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Fig. 1. Anatomy of the pelvic autonomic nerves. (Reprinted with permission of MemorialSloan Kettering Cancer Center.)
be reduced from 9% to 40% to as low as 0% to 11% with TME and ANP [51,53,54]. The rate of sexual dysfunction may be further reduced by using intraoperative nerve stimulators to help identify and preserve the pelvic autonomic nerves [55]. It must be emphasized, however, that factors other than ANP, such as the use of chemoradiation, patient comorbidities, certain medications, and alcohol use, may contribute to urinary and sexual dysfunction after radical rectal resection. Therefore, preoperative evaluation and documentation of these factors is encouraged [4]. Sphincter-preserving resection versus abdominoperineal resection Sphincter preservation is possible for most rectal cancers, in large part because of recent advances in neoadjuvant therapy, surgical skills, instrumentation, and changes in the accepted distal margin length [56]. In specialized centers, sphincter preservation is feasible in most cases when the rectal tumor is located R2 cm above the anorectal ring. Even in patients who have more distally located rectal cancer, sphincter preservation can be carried out with acceptable anorectal function and oncologic outcome by using the technique of intersphincteric resection (ISR) [57,58]. ISR facilitates achievement of a negative distal resection margin by transanal division and resection of all or part of the internal anal sphincter. A recent study that
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analyzed oncologic outcome of ISR in tumors located between 1.5 and 4.5 cm from the anal verge reported that a complete microscopic resection was possible in 89% of the cases, with a local recurrence rate of 2% [57]. However, an APR may be prudent in patients who have infiltration of the external anal sphincter or levator ani muscles, impaired preoperative anal sphincter function, and body habitus or pelvic anatomy that makes sphincter preservation technically challenging [53,59]. The application of sphincter-preserving resection as the procedure of choice in rectal cancer has been validated by studies evaluating long-term oncologic outcome and functional results [59]. Although there are no randomized trials, many comparative studies have reported that sphincter preservation provides for similar short- and long-term oncologic outcomes compared with abdominoperineal resection (APR) [56,59]. In addition, quality of life may be significantly more improved with sphincter preservation than with APR, although anorectal function is not always perfect in patients treated with sphincter-preserving procedures [56,60]. Recently, preoperative CMT with chemoradiation has been used to further increase the likelihood of performing a sphincter-preserving operation, by virtue of tumor bulk reduction. In the recently reported German Rectal Cancer Study by Sauer and colleagues [8], which compared rectal cancer treated with preoperative CMT with rectal cancer treated with postoperative CMT, the sphincter preservation rate among patients who had tumors that were believed to require an APR before treatment was significantly higher in the preoperative CMT group (39% versus 19%, respectively, P ¼ .004). Although sphincter preservation is the optimal therapeutic approach in most cases, APR is indicated when there is tumor invasion of the anal sphincter or pelvic floor. APR is limited by stoma-related complications and a high incidence of perineal wound complications, which have been reported in 7% to 66% of cases [61]. In an attempt to decrease the rate of perineal wound complications after APR, the technique of myocutaneous flap coverage of the perineum has been developed [62–64]. The present authors recently compared rectus abdominus myocutaneous (RAM) flap closure of the perineal wound in patients who had anorectal cancer treated with preoperative chemoradiation, with patients who were treated with primary perineal wound closure. It was reported that perineal closure with a RAM flap significantly decreased the incidence of perineal wound complications (15.8% versus 44.1%, P ¼ .03) [61]. Reconstruction options: straight anastomosis, J-pouch, or coloplasty Classically, bowel continuity after proctectomy was restored with a straight colorectal or coloanal anastomosis. However, after undergoing a straight anastomosis, patients often suffered from difficulties related to anorectal function, including excessive stool frequency, incontinence, urgency, stool clustering, fragmentation, and incomplete evacuation [65]. Incontinence may be the
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result of sphincter injury during the dissection or instrumentation, whereas frequency and urgency are believed to be because of diminished reservoir capacity [59]. In an effort to increase reservoir capacity and improve postoperative anorectal function, a colonic J-pouch in conjunction with a coloanal anastomosis was developed [66]. Using the J-pouch, frequency of defecation was significantly decreased in patients who had undergone proctectomy with coloanal anastomosis. Subsequent reports have also noted a lower frequency of bowel movements in patients treated with the radical rectal resection and J-pouch method [67,68]. However, in some studies, difficulties in defecation or split defecation were observed in patients who had a colonic pouch, which were believed to be related to the length of the pouch [69,70]. A prospective, randomized trial that compared a 6-cm J-pouch with a 10-cm J-pouch demonstrated that patients who have a larger reservoir are more likely to require medications for constipation and evacuation [71]. Currently, a 5- to 6-cm J-pouch is recommended following resection of distal rectal cancer [72,73]. Although colonic J-pouch anastomosis significantly improved quality of life compared with a straight coloanal anastomosis, up to 25% of patients treated with a low anterior resection (LAR) were not candidates for it, in large part because of technical difficulty related to its bulk [72]. Recently, an alternative pouch technique called the transverse coloplasty procedure was introduced [74]. A recent prospective, randomized trial comparing colonic J-pouch with transverse coloplasty has demonstrated similar functional results between the two groups, with improved neorectal sensitivity in the coloplasty group [72]. However, another trial has noted increased leakage rates with transverse coloplasty, with no differences in bowel function when compared with a colonic J-pouch [75]. Because a colonic J-pouch provides optimal postoperative bowel function with low morbidity, it may be the primary method of bowel reconstruction when a coloanal anastomosis is required after LAR. However, when it is not technically feasible a transverse coloplasty may be an acceptable alternative [4].
Laparoscopic approaches Two recently reported prospective, randomized trials have demonstrated that laparoscopically assisted colectomy may be an acceptable alternative to open colectomy for colon cancer [76,77]. These reports suggest similar oncologic outcomes (local recurrence and overall survival) for laparoscopically assisted and open colectomy. In addition, laparoscopically assisted resection may be associated with a shorter hospital stay, with no differences between intra-, peri- and postoperative complications. However, it must be emphasized that these studies excluded rectal cancer and these results may not be applicable to rectal cancer, in which more challenging technical and anatomic considerations are present.
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Data from some nonrandomized studies evaluating laparoscopically assisted rectal cancer resection have demonstrated that laparoscopically assisted TME is feasible and does not seem to impair oncologic outcome when performed by experienced surgeons [78,79]. In addition, short-term outcomes of morbidity, recovery time, hospital stay, and postoperative narcotic requirements may be reduced in the laparoscopic group. Although the laparoscopic approach appears to be associated with potential benefits, we await the results of large, prospective, randomized trials focusing on laparoscopic resection of rectal cancer before definitive recommendations can be made concerning the safety and oncologic efficacy of these procedures. References [1] Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg 1982;69(10):613–6. [2] Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002; 89(3):327–34. [3] Heald RJ, Moran BJ, Ryall RD, Sexton R, et al. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 1998;133(8):894–9. [4] Chessin DB, Guillem JG. Surgical issues in rectal cancer: a 2004 update. Clin Colorectal Cancer 2004;4(4):233–40. [5] Morikawa E, Yasutomi M, Shindou K, et al. Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method. Dis Colon Rectum 1994;37(3):219–23. [6] Hida J, Yasutomi M, Maruyama T, et al. Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision. J Am Coll Surg 1997;184(6):584–8. [7] Lopez-Kostner F, Lavery IC, Hool GR, et al. Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery 1998;124(4):612–7 [discussion: 617–8]. [8] Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351(17):1731–40. [9] Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345(9):638–46. [10] Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 2001;93(8):583–96. [11] Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg 1983;70(3):150–4. [12] Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 1995;76(3):388–92. [13] Kwok SP, Lau WY, Leung KL, et al. Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg 1996;83(7):969–72. [14] Andreola S, Leo E, Belli F, et al. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 1997;40(1):25–9. [15] Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg 1983;198(2):159–63. [16] Vernava AM III, Moran M, Rothenberger DA, et al. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 1992;175(4):333–6.
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[39] Hida J, Yasutomi M, Maruyama T, et al. Results from pelvic exenteration for locally advanced colorectal cancer with lymph node metastases. Dis Colon Rectum 1998;41(2): 165–8. [40] Lopez MJ, Monafo WW. Role of extended resection in the initial treatment of locally advanced colorectal carcinoma. Surgery 1993;113(4):365–72. [41] Russo P, Ravindran B, Katz J, et al. Urinary diversion after total pelvic exenteration for rectal cancer. Ann Surg Oncol 1999;6(8):732–8. [42] Orkin BA, Dozois RR, Beart RW Jr, et al. Extended resection for locally advanced primary adenocarcinoma of the rectum. Dis Colon Rectum 1989;32(4):286–92. [43] Moriya Y, Akasu T, Fujita S, Yamamoto S. Aggressive surgical treatment for patients with T4 rectal cancer. Colorectal Dis 2003;5(5):427–31. [44] Fujisawa M, Nakamura T, Ohno M, et al. Surgical management of the urinary tract in patients with locally advanced colorectal cancer. Urology 2002;60(6):983–7. [45] Talamonti MS, Shumate CR, Carlson GW, et al. Locally advanced carcinoma of the colon and rectum involving the urinary bladder. Surg Gynecol Obstet 1993;177(5):481–7. [46] Block IR, Enquist IF. Lymphatic studies pertaining to local spread of carcinoma of the rectum in the female. Surg Gynecol Obstet 1961;112:41–6. [47] Ruo L, Paty PB, Minsky BD, et al. Results after rectal cancer resection with in-continuity partial vaginectomy and total mesorectal excision. Ann Surg Oncol 2003;10(6):664–8. [48] Yamada K, Ishizawa T, Niwa K, et al. Pelvic exenteration and sacral resection for locally advanced primary and recurrent rectal cancer. Dis Colon Rectum 2002;45(8):1078–84. [49] Moriya Y, Akasu T, Fujita S, et al. Total pelvic exenteration with distal sacrectomy for fixed recurrent rectal cancer in the pelvis. Dis Colon Rectum 2004;47(12):2047–53 [discussion: 2053–4]. [50] Havenga K, Enker WE, McDermott K, et al. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 1996;182(6):495–502. [51] Mitsui T, Kobayashi S, Matsuura S, et al. Vesicourethral dysfunction following radical surgery for rectal carcinoma: change in voiding pattern on sequential urodynamic studies and impact of nerve-sparing surgery. Int J Urol 1998;5(1):35–8. [52] Havenga K, Enker WE. Autonomic nerve preserving total mesorectal excision. Surg Clin North Am 2002;82(5):1009–18. [53] Guillem JG, Cohen AM. Treatment options for mid- and low-rectal cancers. Adv Surg 2000; 34:43–66. [54] Moriya Y, Sugihara K, Akasu T, et al. Nerve-sparing surgery with lateral node dissection for advanced lower rectal cancer. Eur J Cancer 1995;31A(7–8):1229–32. [55] Hanna NN, Guillem J, Dosoretz A, et al. Intraoperative parasympathetic nerve stimulation with tumescence monitoring during total mesorectal excision for rectal cancer. J Am Coll Surg 2002;195(4):506–12. [56] Di Betta E, D’Hoore A, Filez L, et al. Sphincter saving rectum resection is the standard procedure for low rectal cancer. Int J Colorectal Dis 2003;18(6):463–9. [57] Rullier E, Laurent C, Bretagnol F, et al. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg 2005;241(3):465–9. [58] Saito N, Ono M, Sugito M, et al. Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy. Dis Colon Rectum 2004;47(4):459–66. [59] Guillem JG. Ultra-low anterior resection and coloanal pouch reconstruction for carcinoma of the distal rectum. World J Surg 1997;21(7):721–7. [60] Engel J, Kerr J, Schlesinger-Raab A, et al. Quality of life in rectal cancer patients: a four-year prospective study. Ann Surg 2003;238(2):203–13. [61] Chessin DBHJ, Cohen AM, Mazumdar M, et al. Rectus flap reconstruction decreases perineal wound complication after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 2005;12(2):104–10.
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[62] Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 1999;6(1):33–7. [63] Anthony JP, Mathes SJ. The recalcitrant perineal wound after rectal extirpation: applications of muscle flap closure. Arch Surg 1990;125(10):1371–6 [discussion: 1376–7]. [64] Baird WL, Hester TR, Nahai F, et al. Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps. Arch Surg 1990;125(11):1486–9. [65] Schoetz DJ Jr. Postcolectomy syndromes. World J Surg 1991;15(5):605–8. [66] Lazorthes F, Fages P, Chiotasso P, et al. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg 1986; 73(2):136–8. [67] Nicholls RJ, Lubowski DZ, Donaldson DR. Comparison of colonic reservoir and straight colo-anal reconstruction after rectal excision. Br J Surg 1988;75(4):318–20. [68] Kusunoki M, Shoji Y, Yanagi H, et al. Function after anoabdominal rectal resection and colonic J pouch–anal anastomosis. Br J Surg 1991;78(12):1434–8. [69] Parc R, Tiret E, Frileux P, et al. Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma. Br J Surg 1986;73(2):139–41. [70] Pelissier EP, Blum D, Bachour A, et al. Functional results of coloanal anastomosis with reservoir. Dis Colon Rectum 1992;35(9):843–6. [71] Lazorthes F, Gamagami R, Chiotasso P, et al. Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum 1997;40(12):1409–13. [72] Furst A, Suttner S, Agha A, et al. Colonic J-pouch vs. coloplasty following resection of distal rectal cancer: early results of a prospective, randomized, pilot study. Dis Colon Rectum 2003;46(9):1161–6. [73] Laurent A, Parc Y, McNamara D, et al. Colonic J-pouch-anal anastomosis for rectal cancer: a prospective, randomized study comparing handsewn vs. stapled anastomosis. Dis Colon Rectum 2005;48(4):729–34. [74] Z’Graggen K, Maurer CA, Buchler MW. Transverse coloplasty pouch. A novel neorectal reservoir. Dig Surg 1999;16(5):363–6. [75] Ho YH, Brown S, Heah SM, et al. Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Ann Surg 2002;236(1):49–55. [76] Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 2002;359(9325):2224–9. [77] A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350(20):2050–9. [78] Anthuber M, Fuerst A, Elser F, et al. Outcome of laparoscopic surgery for rectal cancer in 101 patients. Dis Colon Rectum 2003;46(8):1047–53. [79] Fleshman JW, Wexner SD, Anvari M, et al. Laparoscopic vs. open abdominoperineal resection for cancer. Dis Colon Rectum 1999;42(7):930–9.
Surgical Treatment of Rectal Cancer: Radical Resection Seung-Yong Jeong, MD, PhDa, David B. Chessin, MDa, Jose G. Guillem, MD, MPHa,b,* a
Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-1077, New York, NY 10021, USA b Cornell University Medical College, 520 East 70th Street, New York, NY 10021, USA
Total mesorectal excision (TME), introduced and popularized by Heald and colleagues [1] in the early 1980s, is the operative technique of sharp rectal mobilization along the avascular plane between the visceral fascia of the mesorectum and the parietal fascia of the pelvic side wall. The mesorectum is defined as the fatty lymphovascular tissue that surrounds the rectum. Although there are benefits to TME, such as preserving the pelvic autonomic nerves and increasing the anal sphincter preservation rate, the most important effect of TME is its improvement in local control of the disease [2,3]. This is clinically important because local failure is associated with decreased survival and the agonizing symptoms of intractable pain, bleeding, and voiding and defecation problems. Although there is a wide variability in the reported local recurrence rate after rectal cancer surgery, it may range from 35% to 45% in patients treated with conventional rectal resection. However, studies of radical rectal resection using the TME technique have reported local recurrence rates ranging from 3% to 11% [4].
Oncologic considerations Total mesorectal excision (TME) Studies that examined the mesorectum of resected upper rectal cancer have revealed that lymph node metastasis in the mesorectum are rarely * Corresponding author. Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-1077, New York, NY 10021. E-mail address: [email protected] (J.G. Guillem). 1055-3207/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.soc.2005.08.007 surgonc.theclinics.com
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beyond 5 cm distal to the mucosal edge of the tumor [1,5,6]. In addition, mesorectal excision beyond 5 cm distal to the tumor may result in an increased risk of anastomotic leakage without any oncologic benefit [7]. Therefore, a partial mesorectal excision with a distal 5-cm resection margin is likely sufficient for upper rectal cancer. The effect of TME on local control has been shown to be further enhanced by adding preoperative radiation therapy (RT). A prospective, randomized trial conducted by Sauer and colleagues for the German Rectal Cancer Study Group [8] compared a protocol consisting of preoperative chemoradiation therapy (5040 cGy plus a continuous intravenous infusion of fluorouracil) followed by TME, with TME followed by postoperative chemoradiation therapy. The 5-year local recurrence rate was significantly lower in the group treated preoperatively with chemoradiation, although the 5-year overall survival rates were not different between the two groups. Another prospective, randomized trial by Kapiteijn and colleagues for the Dutch Colorectal Cancer Group [9] compared preoperative short-course radiation therapy (500 cGy on each of 5 days) followed by TME (RT plus TME) with TME alone. The 2-year local recurrence rates were significantly lower in the RT-plus-TME group (2.4%) than in the TME-alone group (8.2%), but 2-year overall survival and distant recurrence rates were not different between the two groups. Therefore, it appears that neoadjuvant therapy followed by TME provides for further improvement in local recurrence rates. Distal resection margin Classically, the recommended distal resection margin for rectal cancer resection was 2 cm or greater [10]. However, several studies have shown that distal intramural spread of tumor rarely exceeds 2 cm, and local control and survival may not be compromised by shorter distal margins [11–14]. In addition, although in rare cases distal spread is found beyond 1 to 2 cm, it is often associated with tumors of advanced stage or unfavorable histologic features, and the poor prognosis in these patients is not improved by a resection margin longer than 2 cm [15]. Therefore, for tumors of the distal rectum, a 1-cm distal margin may be acceptable [14,16]. In addition, the present authors recently reported that a negative distal margin of less than 1 cm does not seem to compromise oncologic outcome when patients are treated preoperatively with combined modality therapy (CMT) and TME [17]. Circumferential resection margin The importance of the circumferential resection margin (CRM) was highlighted by Quirke and colleagues [18], who reported that a positive CRM in rectal cancer is associated with significantly worse local control. This finding was supported by a recent series reporting that a CRM of less than 2 mm was associated with a significant increase in local recurrence (16.0% versus
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5.8%, respectively, P % .0001) in 656 patients who had rectal cancer treated with TME [19]. Adjuvant radiation therapy has been given to reduce local recurrence when a negative CRM cannot be obtained. However, some data have suggested that it does not compensate for a positive CRM [20]. The present authors currently recommend resection of rectal cancer according to the principles of TME, with all efforts made to obtain a negative CRM, including en bloc resection of contiguous structures when it is clinically indicated. Level of vascular ligation Historically, some investigators have recommended ligation of the inferior mesenteric artery (IMA) at its origin (high ligation) [21]; however, there has been no prospective study that directly compared the outcome between the use of high ligation with low ligation in rectal cancer patients. However, for patients who have distal colon cancers, a French multicenter, prospective, randomized trial by Rouffet and colleagues [22], who compared left colectomy and high ligation of IMA with segmental colectomy and ligation of the primary feeding vessels, has shown no significant difference in longterm survival between the two groups. A potential risk of high ligation of the IMA includes injury to the hypogastric plexus near the posterior aspect of superior rectal artery, where it lies immediately anterior to the aorta. Currently, the recommended level of proximal vascular ligation for rectal cancer is at the origin of the superior rectal artery, which is immediately distal to the takeoff of the left colic artery [10]. However, for ultradistal colorectal or coloanal anastomosis, in which a full splenic flexure mobilization is required, a high ligation may be necessary to facilitate sacralization of the neorectum and a tension-free anastomosis. No-touch isolation technique The no-touch technique is a procedure composed of initial ligation of the lymphovascular pedicle of the tumor and subsequent proximal and distal luminal blockade with ligature or clamping before manipulation of the tumor mass. Since Turnbull and colleagues [23] reported an improved 5-year survival in patients in whom the no-touch isolation technique was applied, this procedure became regarded as a potentially useful technique. The survival benefit of this technique is hypothesized to be the result of limiting the influx of tumor cells into circulation during resection. However, the only prospective, randomized trial that compared the effect of the no-touch isolation technique with conventional colon cancer resection demonstrated no significant difference in 5-year survival between the groups [24]. Currently, a rectal cancer resection begins with mobilization of the sigmoid colon from its lateral location by incising congenital adhesions and the white line of Toldt. Following this procedure, the left ureter is identified
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proximally and displaced laterally. Proximal vascular ligation is then accomplished before rectal mobilization. Rectal washout Viable tumor cells in washing samples from the rectal resection margin, rectal stump, and circular stapling device have been reported [25,26]. Cells from these washings may be proliferative and have metastatic potential. Some authors suggest that preresection rectal washout with a cytocidal solution may improve local control and oncologic outcome [27]. However, a recent retrospective study that compared patients who had rectal cancer treated with rectal washout using a cytocidal drug followed by resection, and a control group treated with no washout and resection, did not demonstrate a difference in local recurrence between the groups [28]. Although there is no conclusive evidence that supports rectal washout, it has very low risk, minimal cost, and potential benefit and thus may be applicable during rectal cancer surgery [10]. Lateral node dissection For low rectal cancers, lymphatic spread occurs not only upward to mesenteric nodes along the superior rectal and inferior mesenteric vessels but also laterally to the hypogastric, obturator, and presacral lymph nodes along the middle rectal, sacral, and iliac vessels. Lateral lymph node metastases have been reported in up to 13% of rectal cancers located below the peritoneal reflection and as high as 25% in Dukes’ stage C rectal cancer [29]. The local failure rate is high, and the long-term prognosis is dismal in patients who have positive lateral lymph nodes, even compared with patients who have positive mesorectal lymph nodes [30]. Several retrospective studies from Japan have reported improved local control and survival when extended lateral lymph node dissection is performed. The authors recommend this procedure in patients who have low-lying rectal cancer invading the muscularis propria or deeper [31]. However, before routinely applying lateral lymph node dissection in clinical practice, it is necessary to determine whether the involvement of lateral lymph nodes is solely an indicator of advanced, incurable disease or whether the identification of positive lateral lymph nodes and lymphadenectomy provide for improved oncologic outcome. To date, no well-controlled prospective trial has demonstrated a benefit of lateral lymph node dissection on oncologic outcome. Moreover, this procedure has been associated with considerable impairment of genitourinary function. Currently, there is insufficient evidence to recommend a routine lateral lymph node dissection for patients who have distal rectal cancer. However, it may be performed when lateral lymph node metastasis is suspected by preoperative imaging studies or intraoperative findings, and when it is technically feasible.
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Recently, preoperative radiation therapy has been suggested as an alternative modality to lateral lymph node dissection in locally advanced rectal cancer [32]. A randomized, controlled trial of 51 patients who had locally advanced rectal cancer treated with preoperative radiation therapy has demonstrated no difference in survival and recurrence between patients treated with lateral lymph node dissection and those without. Future research efforts should focus on determining whether select subgroups of patients may benefit from extended lateral lymph node dissection. Sentinel lymph node mapping Lymph node metastases are the best predictor of survival in patients who have rectal cancer. Currently, there are no reliable methods that can determine precisely the lymph node status pre- or intraoperatively. However, some authors suggest that sentinel lymph node mapping may be an acceptable means of intraoperative determination of lymph node status in rectal cancer patients [33,34]. The sentinel lymph node mapping technique has been applied to colorectal cancer and found to be feasible, but concerns over accuracy and high false-negative rates have restricted its routine use in the clinical setting [33–36]. Moreover, it is less accurate in patients who received preoperative chemoradiation, likely because of its impact on lymphatic flow to and from the tumor [37]. Currently, sentinel lymph node mapping has a limited role in the management of rectal cancer. However, it may be worth studying in selected settings, such as in determining the value of extended lateral lymph node dissection for patients who have distal rectal cancer [38]. Extended resection: posterior vaginectomy, pelvic exenteration, and sacrectomy Direct tumor invasion into adjacent organs or structures is encountered in 6% to 10% of patients who have rectal cancer [39,40]. Contiguous tumor spread most commonly involves the uterus, adnexa, and posterior vaginal wall in females and seminal vesicles, prostate, and bladder in males. En bloc resection of the tumor with involved adjacent tissue should be performed whenever possible because it is associated with lower local recurrence and improved cancer-related survival [41,42]. A major consideration for the surgeon is that often it cannot be accurately determined whether the involvement of contiguous organs is the result of an inflammatory process or of malignant invasion. In this situation, the surgeon should proceed with en bloc resection when technically feasible [10]. The urinary bladder is the organ most frequently involved by locally advanced rectal cancer, and extended resection may include a partial or a total cystectomy [43,44]. Although morbidity rates may be increased following
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bladder resection, urinary diversion, or bladder repair, these procedures may prolong survival when resection margins are negative [45]. In female patients, the rectum and vagina lie in close proximity and have a communicating lymphatic system [46]. Therefore, local recurrence may be found in the posterior vaginal wall after rectal cancer resection. A review of 64 patients who required a partial vaginectomy while undergoing resection for primary rectal cancer documented a 46% 5-year overall survival and 16% local failure rate [47]. Local recurrence was more commonly found in patients who have positive surgical margins. Therefore, a partial vaginectomy is indicated for locally advanced rectal cancers involving the vagina, and may result in an improved long-term oncologic outcome [47]. More extensive surgery, such as total pelvic exenteration, with or without sacral resection, is more commonly used for recurrent cancer, but it may be indicated for selected primary rectal cancers [48]. Although the associated morbidity is high, careful patient selection may result in tolerable functional outcome and prolonged survival following these aggressive procedures [40,48,49].
Functional and technical considerations Autonomic nerve preservation and urinary and sexual function The pelvic sympathetic nerves originate from the splanchnic branches of T12 to L2, forming the preaortic superior hypogastric plexus [50]. The superior hypogastric plexus extends from an area just distal to the aortic bifurcation to the sacral promontory and then gives rise to the right and left hypogastric nerves (Fig. 1). The hypogastric nerves lie in the areolar tissue plane between the visceral fascia of the mesorectum and the parietal fascia covering the pelvic sidewall. The plane between the visceral and parietal fascia is very thin at the level of the pelvic brim, and the pelvic autonomic nerves are especially vulnerable to injury at this location during dissection. Injury to the hypogastric nerves results in increased bladder tone with reduced bladder capacity, voiding difficulty, impaired (retrograde) ejaculation in men, and the loss of vaginal lubrication and dyspareunia in women [4,50]. The parasympathetic nerves of the pelvis (nervi erigentes) arise from the S2–4 anterior spinal nerve roots and join the hypogastric nerves on the pelvic sidewall to form the inferior hypogastric plexus (see Fig. 1) [50]. Damage to the parasympathetic nerves leads to erectile dysfunction, impaired vaginal lubrication, and voiding difficulty [51]. Truncal autonomic nerve preservation (ANP) is defined as preservation of the anterior nerve roots of S2–4 and the superior hypogastric plexus [52]. With careful ANP, postoperative genitourinary and sexual dysfunction can be reduced from 25% to 75% with conventional resection to as low as 10% to 28% [53]. More specifically, the incidence of neurogenic bladder can
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Fig. 1. Anatomy of the pelvic autonomic nerves. (Reprinted with permission of MemorialSloan Kettering Cancer Center.)
be reduced from 9% to 40% to as low as 0% to 11% with TME and ANP [51,53,54]. The rate of sexual dysfunction may be further reduced by using intraoperative nerve stimulators to help identify and preserve the pelvic autonomic nerves [55]. It must be emphasized, however, that factors other than ANP, such as the use of chemoradiation, patient comorbidities, certain medications, and alcohol use, may contribute to urinary and sexual dysfunction after radical rectal resection. Therefore, preoperative evaluation and documentation of these factors is encouraged [4]. Sphincter-preserving resection versus abdominoperineal resection Sphincter preservation is possible for most rectal cancers, in large part because of recent advances in neoadjuvant therapy, surgical skills, instrumentation, and changes in the accepted distal margin length [56]. In specialized centers, sphincter preservation is feasible in most cases when the rectal tumor is located R2 cm above the anorectal ring. Even in patients who have more distally located rectal cancer, sphincter preservation can be carried out with acceptable anorectal function and oncologic outcome by using the technique of intersphincteric resection (ISR) [57,58]. ISR facilitates achievement of a negative distal resection margin by transanal division and resection of all or part of the internal anal sphincter. A recent study that
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analyzed oncologic outcome of ISR in tumors located between 1.5 and 4.5 cm from the anal verge reported that a complete microscopic resection was possible in 89% of the cases, with a local recurrence rate of 2% [57]. However, an APR may be prudent in patients who have infiltration of the external anal sphincter or levator ani muscles, impaired preoperative anal sphincter function, and body habitus or pelvic anatomy that makes sphincter preservation technically challenging [53,59]. The application of sphincter-preserving resection as the procedure of choice in rectal cancer has been validated by studies evaluating long-term oncologic outcome and functional results [59]. Although there are no randomized trials, many comparative studies have reported that sphincter preservation provides for similar short- and long-term oncologic outcomes compared with abdominoperineal resection (APR) [56,59]. In addition, quality of life may be significantly more improved with sphincter preservation than with APR, although anorectal function is not always perfect in patients treated with sphincter-preserving procedures [56,60]. Recently, preoperative CMT with chemoradiation has been used to further increase the likelihood of performing a sphincter-preserving operation, by virtue of tumor bulk reduction. In the recently reported German Rectal Cancer Study by Sauer and colleagues [8], which compared rectal cancer treated with preoperative CMT with rectal cancer treated with postoperative CMT, the sphincter preservation rate among patients who had tumors that were believed to require an APR before treatment was significantly higher in the preoperative CMT group (39% versus 19%, respectively, P ¼ .004). Although sphincter preservation is the optimal therapeutic approach in most cases, APR is indicated when there is tumor invasion of the anal sphincter or pelvic floor. APR is limited by stoma-related complications and a high incidence of perineal wound complications, which have been reported in 7% to 66% of cases [61]. In an attempt to decrease the rate of perineal wound complications after APR, the technique of myocutaneous flap coverage of the perineum has been developed [62–64]. The present authors recently compared rectus abdominus myocutaneous (RAM) flap closure of the perineal wound in patients who had anorectal cancer treated with preoperative chemoradiation, with patients who were treated with primary perineal wound closure. It was reported that perineal closure with a RAM flap significantly decreased the incidence of perineal wound complications (15.8% versus 44.1%, P ¼ .03) [61]. Reconstruction options: straight anastomosis, J-pouch, or coloplasty Classically, bowel continuity after proctectomy was restored with a straight colorectal or coloanal anastomosis. However, after undergoing a straight anastomosis, patients often suffered from difficulties related to anorectal function, including excessive stool frequency, incontinence, urgency, stool clustering, fragmentation, and incomplete evacuation [65]. Incontinence may be the
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result of sphincter injury during the dissection or instrumentation, whereas frequency and urgency are believed to be because of diminished reservoir capacity [59]. In an effort to increase reservoir capacity and improve postoperative anorectal function, a colonic J-pouch in conjunction with a coloanal anastomosis was developed [66]. Using the J-pouch, frequency of defecation was significantly decreased in patients who had undergone proctectomy with coloanal anastomosis. Subsequent reports have also noted a lower frequency of bowel movements in patients treated with the radical rectal resection and J-pouch method [67,68]. However, in some studies, difficulties in defecation or split defecation were observed in patients who had a colonic pouch, which were believed to be related to the length of the pouch [69,70]. A prospective, randomized trial that compared a 6-cm J-pouch with a 10-cm J-pouch demonstrated that patients who have a larger reservoir are more likely to require medications for constipation and evacuation [71]. Currently, a 5- to 6-cm J-pouch is recommended following resection of distal rectal cancer [72,73]. Although colonic J-pouch anastomosis significantly improved quality of life compared with a straight coloanal anastomosis, up to 25% of patients treated with a low anterior resection (LAR) were not candidates for it, in large part because of technical difficulty related to its bulk [72]. Recently, an alternative pouch technique called the transverse coloplasty procedure was introduced [74]. A recent prospective, randomized trial comparing colonic J-pouch with transverse coloplasty has demonstrated similar functional results between the two groups, with improved neorectal sensitivity in the coloplasty group [72]. However, another trial has noted increased leakage rates with transverse coloplasty, with no differences in bowel function when compared with a colonic J-pouch [75]. Because a colonic J-pouch provides optimal postoperative bowel function with low morbidity, it may be the primary method of bowel reconstruction when a coloanal anastomosis is required after LAR. However, when it is not technically feasible a transverse coloplasty may be an acceptable alternative [4].
Laparoscopic approaches Two recently reported prospective, randomized trials have demonstrated that laparoscopically assisted colectomy may be an acceptable alternative to open colectomy for colon cancer [76,77]. These reports suggest similar oncologic outcomes (local recurrence and overall survival) for laparoscopically assisted and open colectomy. In addition, laparoscopically assisted resection may be associated with a shorter hospital stay, with no differences between intra-, peri- and postoperative complications. However, it must be emphasized that these studies excluded rectal cancer and these results may not be applicable to rectal cancer, in which more challenging technical and anatomic considerations are present.
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Data from some nonrandomized studies evaluating laparoscopically assisted rectal cancer resection have demonstrated that laparoscopically assisted TME is feasible and does not seem to impair oncologic outcome when performed by experienced surgeons [78,79]. In addition, short-term outcomes of morbidity, recovery time, hospital stay, and postoperative narcotic requirements may be reduced in the laparoscopic group. Although the laparoscopic approach appears to be associated with potential benefits, we await the results of large, prospective, randomized trials focusing on laparoscopic resection of rectal cancer before definitive recommendations can be made concerning the safety and oncologic efficacy of these procedures. References [1] Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg 1982;69(10):613–6. [2] Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 2002; 89(3):327–34. [3] Heald RJ, Moran BJ, Ryall RD, Sexton R, et al. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 1998;133(8):894–9. [4] Chessin DB, Guillem JG. Surgical issues in rectal cancer: a 2004 update. Clin Colorectal Cancer 2004;4(4):233–40. [5] Morikawa E, Yasutomi M, Shindou K, et al. Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method. Dis Colon Rectum 1994;37(3):219–23. [6] Hida J, Yasutomi M, Maruyama T, et al. Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision. J Am Coll Surg 1997;184(6):584–8. [7] Lopez-Kostner F, Lavery IC, Hool GR, et al. Total mesorectal excision is not necessary for cancers of the upper rectum. Surgery 1998;124(4):612–7 [discussion: 617–8]. [8] Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351(17):1731–40. [9] Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345(9):638–46. [10] Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 2001;93(8):583–96. [11] Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg 1983;70(3):150–4. [12] Shirouzu K, Isomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer 1995;76(3):388–92. [13] Kwok SP, Lau WY, Leung KL, et al. Prospective analysis of the distal margin of clearance in anterior resection for rectal carcinoma. Br J Surg 1996;83(7):969–72. [14] Andreola S, Leo E, Belli F, et al. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 1997;40(1):25–9. [15] Pollett WG, Nicholls RJ. The relationship between the extent of distal clearance and survival and local recurrence rates after curative anterior resection for carcinoma of the rectum. Ann Surg 1983;198(2):159–63. [16] Vernava AM III, Moran M, Rothenberger DA, et al. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet 1992;175(4):333–6.
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