Evidence - Rectal resection, open, low anterior with total mesorectal excision (TME) - general and visceral surgery
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Definition of colon and rectal cancer
According to the international classification system, rectal carcinomas are tumors whose proximal margin is 16cm or less from the anocutaneous line when measured with rigid rectoscopy [1, 2]. A distinction is made between
- the inferior third (0-6cm),
- the middle third (6-12cm) and
- the superior third (12-16cm) .
In the USA, however, tumors up to 12cm from the anocutaneous line are referred to as rectal cancer, while those beyond the 12cm limit are classified as colon cancer .
Shortened TNM classification of colorectal carcinoma 
Stage TNM Depth of invasion/tumor spread I T1N0
T2N0 Muscularis propria II T3N0 Perirectal tissue: Mesorectum T4N0
T4a Visceral peritoneum
T4b Other organs/structures
N1a Metastasis in 1 regional lymph node
N1b Metastasis in 2–3 regional lymph nodes
N1c Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis
N2a Metastasis in 4–6 regional lymph nodes
N2b Metastasis in 7 or more regional lymph nodes
M1a Metastasis confined to 1 organ or site (e.g., liver, lung, ovary, nonregional node) without peritoneal metastasis
M1b Metastasis to two or more sites or organs without peritoneal metastasis
M1c Metastasis to the peritoneal surface alone or with other site or organ metastases
Because of the complex therapy, all colorectal carcinomas should be presented to a tumor board prior to therapy (e.g., surgery, chemotherapy) to develop a joint treatment protocol. A study from the UK demonstrated a significant increase in patient survival when this regimen was followed .
A pretreatment board decision is particularly recommended in the following settings:
- All rectal cancers
- All stage IV colon cancers
- Distant metastases
- Local recurrences
- Before any local resection measures
In rectal cancer, for example, it can be evaluated if the patient should undergo neoadjuvant radiochemotherapy. In one study, pretherapeutic case conferences also significantly lowered the rate of tumor-positive resection margins in the surgical specimens . In the presence of distant metastasis, it can be evaluated if palliation or ablation should be pursued, and whether distant metastases (e.g., liver metastases) should be resected synchronously or in a second procedure. Patients with distant metastases who have initially undergone chemotherapy should be presented again to clarify whether secondary resectability of the metastases is given. Repeated presentation of patients in tumor boards has increased the rate of metastatic surgery .
Staging of rectal cancer comprises
- Complete colonoscopy, biopsy of any synchronous other tumors
- Abdominal ultrasonography
- Chest film
- Rigid rectoscopy, possibly with biopsy and measurement of distance to dentate line
- Pelvic MRI with measurement of distance between tumor and mesorectal fascia
- Rectal endoluminal ultrasonography as alternative to MRI
Rectal digital examination is also mandatory (assessment of sphincter function, in low rectal cancer assessment of possible sphincter preservation).
Synchronous other tumors can be expected in 5% of colorectal cancer. Therefore, complete colonoscopy should be performed before surgery [9, 10, 11]. If this is not possible because of a stenotic tumor, preoperative imaging modalities (CT or MR colonography) come into play . In these cases, the patient should undergo colonoscopy 3–6 months after surgery, irrespective of the imaging modality originally employed.
In rectal cancer, the rate of distant metastasis at the time of initial diagnosis is 18%. 14% of the distant metastases are found in the liver, 4% in the lungs, 3% along the peritoneum, and 2% in nonregional lymph nodes. Basic work-up of liver metastases comprises abdominal ultrasonography and a CT study of the abdomen [13, 14].
At the time of initial diagnosis, the level of the tumor marker CEA is elevated in about 30% of all colorectal cancers and should therefore be determined preoperatively. In the follow-up of tumor marker expressing malignancies, the CEA level is a reliable indicator of recurrence, and in liver metastases also an independent prognostic factor. At present, the significance of CA 125 as a follow-up parameter in follow-up treatment of confirmed peritoneal metastasis is unclear [15, 16, 17].
Importance of local staging in rectal cancer
In rectal cancer, local staging plays a decisive role when planning further treatment:
Low risk T1 carcinoma: Local excision Resection according to oncologic criteria T3 = Invasion of the mesorectum: Neoadjuvant therapy T4 = Invasion of neighboring organs: Neoadjuvant radiochemotherapy
For T3 carcinomas, data show that the extent of mesorectal invasion (especially the distance to the mesorectal fascia) is of major prognostic significance . In total mesorectal excision (TME), this level represents the circumferential resection margin (CRM). If the cancer spread in the mesorectum is to within 1mm of the fascia or has already invaded it (CRM+), the risk of local recurrence is significantly increased . Another prognostic factor is lymph node involvement .
In a 2004 meta-analysis studying data on EUS, MRI and CT until 2002, EUS demonstrated the highest accuracy in T1 cancer ; this result was confirmed in a more recent meta-analysis . An alternative to EUS is MRI with an endorectal coil (more expensive, uncomfortable for patients, hardly available). Compared to MRI and CT, EUS was more sensitive in the differentiation of T2 and T3 carcinomas , whereas in T4 cancer the various imaging modalities did not differ significantly. When visualizing the mesorectal fascia and its relations with the tumor, MRI has the highest sensitivity . While spiral CT is an alternative for fascial assessment , EUS cannot visualize the fascia.
Radical surgery in rectal cancer
Curative radical resection of rectal cancer usually comprises complete resection of the primary tumor as well as partial or total resection of the mesorectum and thus of the regional lymphatics . Curative resection by local measures (full-thickness resection) is only possible in selected cases fulfilling strict criteria.
If the criteria of oncologic surgery are met, the following surgical procedures can be regarded as equivalent, depending on the location of the tumor, relation with the dentate line and levator ani, depth of invasion, and sphincter function:
- Low anterior resection
- Abdominoperineal resection
- Intersphincteric resection (abdominoperanal resection)
1. Removal of the regional lymphatics and division of the inferior mesenteric artery at least distal to the origin of the left colic artery. The value of lymph node dissection along the trunk of the inferior mesenteric artery proximal to the origin of the left colic artery is not known [25 - 28]. The same applies to the dissection of the lateral lymph nodes along the internal iliac artery and its branches [31 - 34].
2. Total mesorectal excision (TME) in cancer of the middle and inferior third of the rectum and partial mesorectal excision in cancer of the superior third of the rectum by sharp dissection between the visceral and parietal pelvic fasciae along anatomical structures [29, 30].
3. Ensuring an adequate safety margin
- Superior third of rectum: Horizontal division of the rectum with partial mesorectal excision 5cm distal to the gross edge of the tumor [29, 36-39] *
- Middle and inferior third of rectum: TME to the pelvic floor, sparing the superior hypogastric plexus, hypogastric nerves and inferior hypogastric plexus [40 - 42]
-> Well or moderately differentiated low-grade tumor in the inferior third – safety margin of 1-2cm adequate
-> In high-grade tumors > 2cm [43 - 47]
Reasons: In rare cases of T3 and T4 tumors, satellite nodes or lymph node metastases may be present up to 4cm distal to the gross tumor margin.
Reconstruction after total mesorectal excision
The following reconstruction techniques are possible in TME with subsequent juxta sphincteric anastomosis:
- End-to-end coloanal anastomosis
- Colonic J-pouch
- Transverse coloplasty
- Side-to-end anastomosis
Especially the end-to-end coloanal anastomoses lead to higher rates of bowel movement as well as worse fecal continence and quality of life, particularly in the first two years after surgery; for this reason, they are not recommended . The benefits of the colonic J-pouch regarding the functional result have been substantiated the best [48, 49]. To prevent voiding problems, each limb of the pouch should not exceed 6cm in length . In almost 75% of cases it is technically feasible to construct a colonic J-pouch . In terms of functionality, the side-to-end anastomosis is probably equal to the colonic J-pouch , while transverse coloplasty is inferior to the latter .
In radical surgery of rectal cancer with TME and coloanal anastomosis, temporary diversion should be constructed. This can reduce morbidity (anastomotic failure, urgent repeat laparotomy) . Colostomy and ileostomy are regarded as equivalent, but current meta-analyses favor the ileostomy [54, 55]. The stoma site should be marked before surgery. While the ileal stoma should be protruding (> 1cm), the colonic stoma is constructed with only slight elevation.
Local surgical procedures for rectal cancer
Local tumor excision (full-thickness excision) as the sole measure with curative intent (R0 resection) is ontologically adequate in pT1 carcinomas under the following conditions [56 - 59]:
- Maximum tumor diameter 3cm
- Well or moderately differentiated
- No invasion of the lymphatics (low-risk histology)
In comparison to radical surgery, the risk of local recurrence even in low-risk cases is higher, while at the same time their morbidity and mortality are lower; therefore, these risks must be weighed [60, 61]. Studies suggest that the technique of transanal endoscopic microsurgery is superior to open transanal excision with retractors [62, 63].
Since in T1 high-risk cancer (G3/4 and/or lymphatic invasion) and in T2 cancer, the incidence of lymph node metastasis is 10%–20%, local excision alone is not recommended [64, 65].
With the appropriate expertise of the surgeon and suitable selection, laparoscopic resection of colorectal cancer can be performed with the same oncologic results as in open surgery. In the short term, the perioperative morbidity of minimally invasive procedures is lower, while total morbidity and mortality remain unchanged . In the long-term course, no differences between laparoscopic and conventional surgery were found regarding the rate of incisional hernia, adhesion-related revision surgery and tumor recurrence [67, 68]. The British CLASSIC study also proved the oncologic safety of laparoscopic surgery in colorectal cancer [69, 70].
Ongoing trials on this topic
A Prospective, Multicenter, Randomized, Open, Parallel Controlled, Non-inferiority Clinical Trial of Salvage Chemoradiotherapy Versus Radical Total Mesorectal Excision in the Treatment of Intermediate-risk Early Middle-low Rectal Cancer After Local Resection
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