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5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 1
35 PROCEDURES FOR RECTAL CANCER
David A. Rothenberger, M.D., F.A.C.S., and Rocco Ricciardi, M.D.
Rectal cancer is a common and lethal malignancy that is diag- or genitourinary organs); previous irradiation of the pelvis; base-
nosed in more than 42,000 persons in the United States each line bowel and anal sphincter function; smoking status; use of
year.1 In treating this condition, the goals are to cure or control alcohol or other drugs; medical comorbidities; and current med-
the primary cancer, to maintain or restore bowel continuity with ications. In particular, a family history suggestive of a hereditary
normal anal continence, to preserve sexual and bladder function, cancer syndrome should be sought because such a history might
and to minimize other treatment-associated morbidity and mor- call for additional diagnostic testing or affect the extent of bowel
tality. A variety of rectal cancer treatment regimens are now avail- resection.
able, spanning the spectrum from simple polypectomy to pro- During the physical examination, the surgeon should be alert
longed and potentially morbid multimodality regimens involving to the presence of liver enlargement, abdominal tenderness or
neoadjuvant chemoradiation therapy, radical extirpative surgery, masses, lymphadenopathy, and abdominal scars or ventral her-
and adjuvant chemotherapy. nias from previous operations. The integrity and function of the
Choosing the optimal therapy for rectal cancer is a complex anal sphincter are carefully assessed by means of digital rectal
process. Although physicians from different disciplines are often examination. A patient with preexisting fecal incontinence or
involved, it is the colorectal surgeon who generally directs the sphincter injury may be best served by a local procedure or
process of evaluation and treatment. As new knowledge has been abdominoperineal resection (APR) rather than a well-intentioned
acquired and new therapies and techniques have been developed, but ill-conceived heroic effort to save the anal sphincter.
management of rectal cancer has changed dramatically. In this
DETERMINATION OF EXTENT OF LOCAL DISEASE
chapter, we examine the surgeon’s unique and critical role in the
preoperative decisions leading to choice of therapy, review the Evaluation of the extent of the primary rectal cancer is essen-
intraoperative decisions influencing the course of surgical thera- tial for planning appropriate therapy. An easily palpable distal rec-
py, and address key technical aspects of the operations performed tal malignancy that directly invades the anal sphincters usually is
to treat rectal cancer. treated with APR. A large, fixed cancer that invades adjacent
organs, the pelvic sidewalls, or the sacrum usually is treated with
neoadjuvant chemoradiation followed by resection or palliative
Preoperative Evaluation measures. A small, mobile, and readily accessible lesion may be
Evaluation of the patient with rectal cancer includes the follow- amenable to local therapy.
ing: (1) visualization of the tumor and biopsy to determine the pre- Determination of the extent of local disease involves clinical
cise location of the lesion and confirm the diagnosis of adenocar- examination, endoscopic assessment, and diagnostic imaging.
cinoma; (2) accurate staging of the neoplasm by determining the Digital rectal examination, combined with proctoscopy, endorec-
extent of bowel wall penetration (T stage), the presence of metas- tal ultrasonography (ERUS), or magnetic resonance imaging, can
tases to local lymph nodes (N stage), and the presence of metasta- determine the morphology of the lesion, the percentage of the
tic spread to distant sites (M stage); (3) colonoscopy to exclude rectal circumference involved, and the quadrants affected, as well
synchronous lesions or other pathologic conditions of the colon; as the degree of fixation, the adjacent organs invaded, and the
and (4) a thorough medical assessment to determine operative risk. presence of lymph nodes or extrarectal masses. The level of the
A standardized workup facilitates staging and decision making. lesion in relation to the anal sphincters is best assessed by means
of digital rectal examination and ERUS or endorectal MRI. The
HISTORY AND PHYSICAL EXAMINATION
distance of the lesion from the dentate line or the anal verge is
A thorough history and a careful physical examination must be assessed more accurately with rigid proctoscopy than with flexi-
done to assess operative risk so that therapeutic options can be ble endoscopy. Biopsy is required to confirm the suspected diag-
tailored to fit the comorbidities and desires of the patient. In nosis of adenocarcinoma and to ascertain whether any unfavor-
modern series, mortality after radical resection of the rectum able histologic features (e.g., mucin production, lymphovascular
ranges from 2% to 6%,2,3 with the most common causes of death invasion, or signet cell histology) are present.
being myocardial infarction, pneumonia, venous thromboem- ERUS and MRI with endorectal coil are the two most useful
bolism (deep vein thrombosis and pulmonary embolism), anas- methods of determining the T and N stages of rectal cancer. In a
tomotic leakage, and stroke.4 Factors associated with increased combined review of 1,966 patients evaluated with ERUS, staging
mortality include impaired sensorium, low albumin level, elevat- accuracy averaged 88%.5 ERUS was highly (80% to 90%) accu-
ed blood urea nitrogen concentration, and prolonged prothrom- rate in predicting the extent of bowel wall involvement but was
bin time.3 somewhat less (70% to 80%) accurate in identifying lymph node
The history focuses on gaining information that might alter metastases.6 Currently, MRI with endorectal coil, though promis-
the treatment plan or identify preexisting conditions worth ing, is accurate in only 40% to 60% of cases; accordingly, it has not
addressing before an elective procedure. Essential information to replaced ERUS for staging the extent of local disease.7,8 Newer
be elicited includes a personal history of colorectal polyps or can- MRI approaches that employ stronger magnets and do not require
cers; previous operations (especially those involving the digestive insertion of an endorectal coil may prove more accurate. ERUS

2. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 2
has the added advantage of offering a convenient and accurate contrast barium enema or virtual colonoscopy with CT cologra-
means of performing image-directed biopsies of suspicious areas. phy is a suitable alternative. If preoperative surveillance of the
Pelvic computed tomographic scanning is not very accurate in proximal colon is not possible, intraoperative or postoperative
determining the depth of bowel wall involvement or the presence colonoscopy should be done.
of lymph node metastases: the highest accuracy reported for CT
in this setting is approximately 76%,9 and most studies report
much lower figures. Pelvic CT scanning is, however, useful for Operative Planning
detecting extrarectal pelvic spread from rectal cancer. Presacral
PRETREATMENT DECISIONS
stranding, obliteration of normal landmarks lateral to the rectum,
direct invasion of the sacrum or the pelvic sidewalls, invasion into In general, the surgeon is responsible for deciding what the
the bladder or the vagina, and evidence of hydronephrosis are all intent of therapy will be (curative or palliative) and which treat-
signs of extensive pelvic disease. ment or treatments will be employed.To make these decisions, he
or she must carefully consider the clinical staging information in
SEARCH FOR DISTANT METASTASES
the light of the anticipated operative technical challenges, the like-
Evaluation of the patient with rectal cancer must also include ly functional results, and the patient’s level of operative risk,
a search for metastatic disease because the approach to the pri- comorbidities, previous treatments, and specific needs.
mary lesion may change if metastases are present. Few data are Clinical staging is based on integration of information
available on the utility of palliative rectal cancer surgery in the obtained from several sources, including clinical evaluation,
setting of metastatic disease; however, it is generally accepted that imaging studies (e.g., ERUS, CT, MRI, and PET), colonoscopy,
patients who present with asymptomatic or minimally sympto- and histopathologic examination of the specimen obtained via
matic distant metastases but who have major local symptoms biopsy or local excision. Because the information on which it is
resulting from the primary rectal cancer may benefit from some based is obtained before institution of definitive treatment, clini-
form of palliative operation. As a rule, the least morbid procedure cal staging is necessarily a less than perfect means of assessing the
that will relieve the local symptoms is preferred. Often, the cho- extent of disease. Nonetheless, it usually suffices to allow the sur-
sen procedure is palliative proctectomy, but sometimes, a less geon to decide whether the intent of treatment will be curative or
invasive local procedure (e.g., stenting) is an option. Patients who palliative and whether a local procedure, a radical procedure, or
present with advanced and highly symptomatic distant metas- multimodality therapy will be indicated.
tases but who have an asymptomatic primary rectal cancer are A history of previous cancer treatment may influence the
usually best served by therapy directed toward the symptomatic choice of therapy, as may the presence of synchronous lesions,
metastases. The presence of extensive but minimally sympto- metastatic disease, extensive local spread, or unfavorable
matic metastases and a minimally symptomatic primary cancer histopathology. Not infrequently, the ideal treatment is not
of the rectum may mandate use of nonoperative, palliative treat- feasible—either because of patient risk factors and comorbidi-
ment regimens. ties or because the patient refuses to accept the proposed treat-
Distant metastases arise most frequently in the liver and the ment and its associated morbidity (e.g., a permanent colosto-
lungs and are often asymptomatic; accordingly, routine evalua- my)—and the treatment eventually chosen represents a com-
tion for distant disease focuses on assessment of these two sites. promise. The experienced surgeon can counsel the patient
If patients have specific symptoms suggestive of possible metas- about therapeutic options, realistic expectations, and likely
tases to other organs or sites, additional imaging studies are prognosis and obtain informed consent to proceed with a
ordered to explore this possibility. Chest x-ray and CT scanning treatment protocol that is individualized to the specifics of a
are the modalities most commonly employed to identify pul- given case.
monary metastases; CT and MRI scanning are the ones most
TREATMENT PROTOCOLS AND MULTIMODALITY THERAPY
commonly employed to identify liver metastases. An alternative
modality, positron emission tomography (PET), has proved high- Because treatment of rectal cancer is so highly individualized,
ly (96%) sensitive in detecting the primary cancer but is of limit- it is difficult to be dogmatic about what constitutes optimal ther-
ed value in detecting local pelvic lymph node metastases.10 Some apy. Nonetheless, there are certain generally accepted treatment
advocate using PET to detect other organ metastases or involve- guidelines for curative-intent treatment of rectal cancer, based
ment of lymph nodes at distant sites. At present, however, there primarily on pretreatment stage of disease, that are useful for the
is little evidence to justify routine use of PET scanning in the practicing surgeon [see Table 1].12,13 Curative-intent treatment of
workup of rectal cancer. Its major current uses are (1) to clarify rectal cancer involves resection or ablation of all neoplastic tissue,
equivocal findings on other scans and (2) to minimize the risk of which almost always necessitates surgical intervention, usually in
missing a distant metastasis to an unusual site in a patient being the form of a radical resection. In highly select cases, local thera-
considered for a highly morbid resection of an extensive primary py may be indicated. Currently, multimodality therapy that com-
or recurrent rectal cancer. bines operative treatment with perioperative chemoradiation is
increasingly being employed to overcome the persistent problem
ASSESSMENT OF SYNCHRONOUS COLORECTAL NEOPLASMS
of local recurrence.
Total colonoscopy is recommended to exclude or remove syn- Clinical trials designed to assess the efficacy of postoperative
chronous lesions (e.g., polyps and other cancers). It is estimated adjuvant pelvic irradiation in treating advanced cancers of the
that 5% to 10% of rectal cancer patients have synchronous can- rectum demonstrated that appropriate doses of radiation can
cers and 30% have additional adenomatous polyps. The signifi- reduce local recurrence and even improve survival, especially
cance of these other lesions is highlighted by a study of 98 when administered in conjunction with radiation-sensitizing
patients with rectal cancers who underwent full colonoscopic sur- chemotherapy and postoperative adjuvant chemotherapy.14-17 In
veillance before operation; in this study, surgical treatment was the United States, most centers administer 45 to 54 Gy of radia-
altered in 33% of cases.11 If colonoscopy is incomplete, a double- tion to the rectal cancer and the pelvis over a period of 4 to 6

3. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 3
Table 1 Rectal Neoplasms: Curative-Intent Therapy
Pretreatment Stage Preferred Treatment Acceptable Treatment
Stage 0
Tis N0 M0 Local therapy if technically feasible (excision is preferred to ablation Radical resection (APR rarely indicated for Tis N0 M0 lesion) if local
for obtaining pathologic confirmation of T stage) therapy is not feasible or safe
Stage I
T1 N0 M0 (favorable features*) Local therapy ± chemoradiation for distal-third lesions or high-risk Radical resection
patients; radical resection for proximal lesions in good-risk patients
T1 N0 M0 (unfavorable features) Radical resection Local therapy plus chemoradiation
T2 N0 M0 Radical resection (especially if unfavorable features are present and Local therapy plus chemoradiation
for proximal lesions in good-risk patients)
Stage II
T3 N0 M0 Preoperative chemoradiation, radical resection, and adjuvant Radical resection, postoperative chemoradiation, and adjuvant
chemotherapy chemotherapy if pathologically appropriate (no adjuvant therapy
if lesion is early T3 N0 M0)
T4 N0 M0 Preoperative chemoradiation, radical resection with en bloc resec- Radical resection, postoperative chemoradiation, and adjuvant
tion of involved organs, and adjuvant chemotherapy chemotherapy
Stage III
Tany N+ M0 Preoperative chemoradiation, radical resection, and adjuvant Radical resection, postoperative chemoradiation, and adjuvant
chemotherapy chemotherapy
*Lesions with favorable features are those that are exophytic, moderately or well differentiated, nonmucinous, non–signet cell, without lymphovascular invasion, extending around one quar-
ter or less of the circumference of the rectum or no more than 3 cm in diameter, and located so that local therapy options are technically feasible and safe.
PATHOLOGY-BASED STAGING AND POSTTREATMENT
weeks. A 1990 National Institutes of Health consensus conference
DECISIONS
endorsed postoperative multimodality treatment of all stage II
and III rectal cancers.18 Clinical staging that is based on pretreatment assessment must
Several researchers have assessed the use of preoperative be distinguished from pathology-based staging that relies on
neoadjuvant chemoradiation in treating advanced-stage rectal information obtained by means of gross and microscopic exami-
cancers.19,20 It was argued that because preoperative irradiation nation of the resected rectal tumor and the surrounding mesorec-
treats undisturbed, well-oxygenated rectal cancers, it should be tum after radical excision. The classic pathology-based staging
more effective than postoperative irradiation, resulting in system developed by Dukes correlated patient survival with depth
improved local control and better survival. In addition, it was of rectal cancer invasion and local lymph node metastases.24
argued that by decreasing the size of bulky rectal cancers, preop- Many modifications to the Dukes staging system were proposed,
erative irradiation should increase the rate of curative resection but it remained the most widely used system until 1987, when the
and the rate of sphincter preservation.21 It was also thought that American Joint Committee for Cancer Staging and End Results
this neoadjuvant approach should diminish the incidence of the Reporting (now the American Joint Committee on Cancer
radiation injury seen after postoperative irradiation when small [AJCC]) developed a new classification methodology that incor-
bowel is adherent to the pelvic operative site.22 Whereas centers in porated both relevant clinical information and pathology-based
the United States tended to employ a prolonged course of irradi- information.25 The AJCC’s proposed TNM classification system,
ation both preoperatively and postoperatively, many European which has been adopted by the International Union Against
centers, especially in Scandinavia, preferred to use a protocol of Cancer, is clinically useful, simple to use, and accepted worldwide
preoperative short-course, high-dose, hypofractionation irradia- [see Tables 2 and 3].
tion, which usually delivered 25 Gy over a period of 1 week.23 An important principle in managing patients with rectal cancer
There is now considerable evidence that chemoradiation can is to compare the pretreatment clinical stage with the final pathol-
decrease local recurrence rates after radical procedures for rectal ogy-based stage to confirm the appropriateness of the proposed
cancer and that it may improve survival and decrease the need for treatment protocol or to adjust therapy on the basis of new infor-
a permanent colostomy. To date, most studies have used 5-fluo- mation. There is some evidence to indicate that patients who
rouracil–based chemotherapy for radiation sensitization; studies undergo radical procedures immediately after local excision of a
using newer agents may be able to obtain further improvements tumor with unfavorable pathologic characteristics survive longer
in outcome.17 The success achieved by employing perioperative than those who undergo radical resection after a local recur-
chemoradiation in conjunction with radical surgery has led to the rence.26 The finding of a more advanced T stage after local thera-
use of perioperative chemoradiation with local excision in several py may induce the surgeon to proceed with radical resection or to
centers. These promising results must be weighed against the add postoperative chemoradiation to the treatment protocol. The
short- and long-term morbidity associated with chemoradiation. finding of a less advanced T stage after local therapy may induce
At present, the main controversies in the selection of multimodal- the surgeon to recommend observation rather than risk the mor-
ity therapy for rectal cancer are (1) the tumor selection criteria, bidity associated with planned chemoradiation. The presence of
(2) the timing of therapy (preoperative or postoperative), (3) the unsuspected multiple lymph node metastases in the mesorectum
dosing and course of radiation therapy, and (4) the use of after radical resection of a T2 cancer may dictate use of postoper-
chemoradiation in conjunction with local therapy. Discussion of ative chemoradiation. Whether a complete clinical response to
these controversies and other issues surrounding the application neoadjuvant preoperative chemoradiation therapy for advanced-
of chemoradiation and adjuvant chemotherapy in the setting of stage rectal cancer obviates radical resection is an issue that
rectal cancer is beyond the scope of this chapter. remains to be resolved.

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5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 4
Table 2 American Joint Committee on Cancer Proponents of curative-intent local therapy suggest that it is
TNM Clinical Classification of Colorectal Cancer 76 possible to restrict such therapy to select T1 and T2 rectal cancers
that do not have associated lymph node metastases. It is known
Stage Description* that the incidence of lymph node metastases correlates most
closely with the depth of rectal wall invasion and is especially high
Tis Carcinoma in situ if the cancer extends through the wall. These proponents argue
T1 Invades submucosa that preoperative staging with ERUS or MRI can differentiate
Primary tumor (T) T2 Invades muscularis propria intramural (T1–2) cancers from transmural (T3) cancers with a
T3 Invades serosa high degree of accuracy33 and can distinguish most of the T1 and
T4 Invades peritoneal cavity or adjacent organ through
serosa
T2 cancers in which lymph node metastases are present. In addi-
tion, they note that poorly differentiated tumors recur three times
NX Nodes cannot be assessed more often than well-differentiated to moderately differentiated
Regional lymph N0 No regional node metastases
nodes (N) tumors34 and that lymph node metastases are more common if
N1 1–3 positive nodes
preoperative biopsy reveals poor differentiation, lymphovascular
N2 4 or more positive nodes
invasion, mucin production, or signet cell histology. Accordingly,
N3 Positive central nodes
they recommend avoiding curative-intent local therapy if any of
Distant metastasis (M) MX Cannot assess metastases these unfavorable histologic characteristics are present, if imaging
M0 No distant metastases studies suggest involvement of lymph nodes, or if the cancer is
M1 Distant metastases present transmural, arguing that occult lymph node metastases are rarely
*Suffix “m” is used to indicate primary tumors in a single site; prefix “y,” to indicate cancers present if such stringent selection criteria are used. Furthermore,
classified after pretreatment; prefix “r,” to indicate tumors that have recurred; and prefix “a,” advocates of curative-intent local therapy suggest that close post-
to indicate staging at autopsy.
treatment follow-up will detect any local cancer development aris-
ing from occult nodal disease at a point where salvage therapy can
CHOICE OF PROCEDURE still be instituted.
Local Procedures It was hoped that by using these strict criteria for initiating
curative-intent local therapy, T1–2 N0 M0 lesions amenable to
The benefits of local procedures for treatment of rectal cancer such therapy could be reliably identified. Unfortunately, this
include minimal morbidity and mortality and rapid postoperative hope has not been realized [see Local Procedures, Operative
recovery. Such procedures allow preservation of genitourinary Technique, Local Excision, below]. The poor outcomes reported
function and cause only minimal disturbance of anal continence. after local excision of select T1 and T2 cancers of the rectum
In some cases, local therapy is the only alternative to permanent have prompted several centers (including our own) to limit the
colostomy. The major disadvantage of local procedures is that use of curative-intent local therapy by restricting it to favorable
employing them inappropriately will result in high local recur- T1 tumors as staged by ERUS or MRI. Some surgeons recom-
rence rates and compromised survival. Local procedures may be mend further subdividing T1 lesions on the basis of submucosal
used as curative-intent therapy for rectal cancer or as compromise invasion and employing local therapy only for those lesions that
therapy for patients who might not tolerate a radical procedure or extend into the superficial third or the middle third of the sub-
who refuse a recommended radical resection (usually because of mucosa.35,36 Ideally, strictly limiting the indications for local
the potential for a permanent colostomy). Local therapy may also therapy should retain the advantages (e.g., low morbidity) while
be used in select cases for palliation of symptomatic but incurable minimizing the disadvantages (e.g., high local recurrence rates),
rectal cancers. but further studies are needed to determine whether this will be
Curative-intent local therapy is usually restricted to treatment an effective strategy. Clearly, the key to more appropriate use of
of highly favorable, accessible rectal cancers that do not invade the local therapy lies in finding better means of predicting the pre-
anal sphincter, are confined to the rectal wall, and are small cise TNM stage and biologic behavior of rectal cancers before
enough to be totally removed or ablated. Any spread to local initiating therapy.
lymph nodes or distant sites is a contraindication to curative-
intent local therapy. In theory, preoperative selection of such
favorable T1–2 N0 M0 cancers for local treatment should result Table 3 American Joint Committee on Cancer
in minimal morbidity, excellent function, and long-term cancer-
free survival. Staging System for Colorectal Cancer76
Critics of local therapy note that on the basis of final patholo-
gy-based staging after radical resection, as many as 12% of Stage T N M
patients with T1 cancers and 22% of those with T2 cancers have Stage 0 Tis N0 M0
node-positive disease that would not have been treated by local
procedures.27-32 These critics suggest that imaging studies cannot Stage I T1, T2 N0 M0
reliably distinguish node-negative from node-positive T1 and T2 Stage IIA T3 N0 M0
rectal cancers and that treating all T1 and T2 rectal cancers with
local therapy would result in dramatic increases in local recur- Stage IIB T4 N0 M0
rence rates and unacceptable decreases in survival rates. Thus, Stage IIIA T1, T2 N1 M0
they argue that using local therapy as the only form of curative-
Stage IIIB T3, T4 N1 M0
intent treatment is inappropriate even for presumed early rectal
cancer. Some authorities maintain that curative-intent local ther- Stage IIIC Any T N2 M0
apy should be employed only in conjunction with multimodality
Stage IV Any T Any N M1
therapy, even for favorable T1 lesions.

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5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 5
Radical Procedures harbor invasive cancer.With such lesions, it is occasionally helpful
The majority of patients with operable rectal cancer require a to use a large-diameter rigid proctoscope to facilitate snare
radical proctectomy. The primary goal of radical resection is to polypectomy. The goal is to remove the polyp in one piece and
remove the rectal cancer, the rectosigmoid mesentery, and the provide the pathologist with a properly oriented specimen. If the
mesorectum with clear margins. Curative-intent radical resections endoscopist has any suspicion that the polyp may harbor a malig-
may be classified on the basis of the final pathologic assessment as nancy, the polypectomy site should be marked by means of sub-
follows: R0 if all margins are clear, R1 if microscopic tumor is pres- mucosal injection and the precise level of the lesion recorded in
ent at the margin, and R2 if gross disease is present. the procedure note.
For the first half of the 20th century, APR with permanent Benign-appearing sessile polyps of the rectum are generally
colostomy was accepted as the treatment of choice for most rec- best removed in one piece by means of transanal local submucos-
tal cancers. Improvements in perioperative care, anesthesia, and al or full-thickness operative excision rather than piecemeal by
surgical technique; the development of reliable bowel-stapling means of endoscopic snare excision. This approach provides the
devices; and improved understanding of the extent and nature of pathologist with a single specimen that can be properly oriented
the spread of rectal cancer led to reductions in operative and can- for histologic examination to assess the depth of tissue invasion. It
cer-related mortality and made anal sphincter–sparing operations also avoids the difficulties that arise when an unsuspected invasive
increasingly reliable and popular. Gradually, anterior resection cancer is identified microscopically but inability to orient the mul-
with colorectal anastomosis became the preferred procedure for tiple pieces of tissue removed by piecemeal excision precludes
proximal rectal and midrectal cancers. accurate assessment of the T stage.
Radical extirpation, with or without colorectal anastomosis, Snare polypectomy by itself is adequate for treating cancer aris-
remained the only treatment option for most rectal cancers until ing in a rectal polyp if the lesion is noninvasive (i.e., confined to
the last quarter of the 20th century, when multimodality therapy the mucosa) or if an invasive cancer is confined to the head, neck,
was proved to be effective. Currently, surgeons frequently com- or stalk of a pedunculated polyp and the margins are clear. If
bine chemoradiation with radical resection and increasingly per- tumor is present within 2 mm of the margin or if the cancer
form restorative procedures even for distal rectal cancers. Despite extends into the submucosa of a pedunculated or sessile polyp,
these improvements, local recurrence and poor function contin- additional therapy is usually indicated. Various options are avail-
ue to be major sources of morbidity and mortality after radical able for such therapy, including transanal excision of the rectal
resection. wall along with the base of the polyp (for accurate determination
of the T stage), chemoradiation, and radical resection.The factors
that determine whether local therapy is sufficient for cancers aris-
Local Procedures ing in a polyp or whether radical resection or adjuvant therapy is
Local procedures used to treat rectal cancer include polypecto- indicated are reviewed elsewhere.37
my, excision, fulguration, and endocavitary radiation. Poly-
pectomy and excision have the advantage of providing a biopsy Local Excision
specimen that can be examined to determine the depth of tumor The goal of local excision procedures is to perform a full-thick-
invasion and thereby confirm or change the preoperative T stage. ness resection of the primary rectal cancer with a 1.0 cm margin.
If microscopic examination of the specimen shows involvement of Local excision is most often accomplished via an endoanal
the circumferential or deep margins or if the pathologic T stage is (transanal) approach under direct vision or by means of transanal
more advanced than the preoperative clinical T stage, radical endoscopic microsurgery (TEM).The endoanal approach is gen-
surgery or chemoradiation may be employed to improve local con- erally suitable for more distal tumors up to 10 cm from the anal
trol. It is not clear whether this approach—excisional biopsy with verge, whereas TEM is appropriate for more proximal cancers.
subsequent additional therapy depending on final pathologic Posterior approaches to excision are rarely necessary.
examination of the specimen—compromises survival in compari- Occasionally, it is helpful to expose the anorectum via a parasacral
son with a more aggressive initial approach. Obviously, this incision so as to facilitate local excision of a rectal cancer that is
approach is not feasible if local ablative techniques (e.g., endocav- otherwise difficult to access. Currently, transsacral and transper-
itary radiation or fulguration) are employed, because the primary ineal approaches are infrequently used because of the significant
lesion is destroyed and thus unavailable for pathologic study. associated morbidity (i.e., wound infections, bowel fistulas, and
Endocavitary radiation has the distinct advantage of being per- impaired continence).Tumors closer to the anal verge may involve
formed in the outpatient setting with local anesthesia with seda- the anal sphincter; such involvement is a contraindication to local
tion; however, it requires special equipment and expertise and is excision unless the patient is unfit for a more aggressive option.
not widely available. Fulguration is now used primarily for pallia-
tion. Its main advantage is that it controls bleeding from incurable Endoanal local excision Because of its relative simplicity
rectal cancers with minimal morbidity. None of the local therapy and excellent safety record, transanal excision is the most com-
techniques include removal of the mesorectum; thus, lymph monly performed local procedure [see Figure 1]. Full mechanical
nodes are not assessed, and it is impossible for the pathologist to bowel preparation is recommended to reduce the possibility of
confirm or alter the preoperative N stage. postoperative impaction and to maintain optimal visualization.
The procedure can be performed with the patient in either the
OPERATIVE TECHNIQUE lithotomy or the prone jackknife position. The prone position has
the advantages of providing easier access for an assistant surgeon
Polypectomy and of being suitable for rectal cancers in any quadrant; the lithot-
Snare polypectomy is most often done during colonoscopic omy position is most suitable for distal posterior tumors. The use
examination of the entire colon with the assumption that the rec- of headlights or lighted retractors is highly recommended. A Lone
tal polyp is benign. Polyps larger than 1.0 cm, polypoid villous Star self-retaining retractor or Gelpi retractors may be used to
adenomas, and polyps with firm ulcerated areas are more likely to efface the anus, and a handheld bivalve retractor, a Ferguson-Hill

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5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 6
a b c
Interrupted
Lesion Excision Site Closure
Figure 1 Local excision. (a) The rectal lesion is exposed with a bivalve retractor. (b) Full-thickness
excision of the lesion is performed. (c) The defect is closed with interrupted sutures.
retractor, or a Parks anoscope may be used to provide endoanal that such trials will ever be successfully completed. Studies involv-
exposure of the lesion. Deep retractors (e.g., narrow Deaver ing short-term follow-up have not demonstrated any impact on
retractors) are often helpful for exposing more proximal cancers. cancer-free survival for T1 cancers but have indicated that survival
Dissection may be facilitated by injecting saline or a local anes- is compromised if T2 cancers are treated with local excision alone.
thetic with epinephrine solution into the rectal wall near the More information is needed before definitive therapeutic recom-
lesion. It is sometimes helpful to place a traction suture 2 cm dis- mendations can be made.
tal to the lesion to facilitate prolapse of the rectal wall before dis- Local recurrence rates after local excision can be lowered by
section is begun. An electrocautery with a needle tip is generally adding adjuvant radiation therapy, with or without chemotherapy.
employed to perform a full-thickness excision of the cancer with Estimated local recurrence rates after adjuvant therapy range
a 1.0 cm margin, but surgeons are increasingly using laparoscop- from 0% to 9% for T1 tumors and from 0% to 24% for T2
ic instruments to facilitate local excision. Hemostasis and orienta- tumors.39-41 Reliable long-term survival data are unavailable. To
tion must be maintained. If desired, the defect in the rectal wall date, only three small retrospective series have evaluated a promis-
may be closed as the dissection progresses. Each suture can be ing newer approach: neoadjuvant therapy followed by local exci-
used for traction to keep the lesion in view. Innovative techniques sion of early-stage, favorable rectal cancers. Clinical trials aimed
making use of laparoscopic or conventional staplers have also at studying this approach are being developed.
been developed and have yielded good results.
Once the specimen has been resected, it is inspected to confirm Transanal endoscopic microsurgery TEM is a novel
that adequate margins have been obtained, then marked for ori- technique that has found a niche in local treatment of sessile
entation and pinned out for fixation before histologic examina- polyps and of favorable T1 cancers in the middle to upper rectum.
tion. The operative site may be irrigated with sterile water or It may be used in combination with chemoradiation to treat more
tumoricidal agents to minimize the risk that viable tumor cells will advanced cancers of the middle and upper rectum, especially in
be left in the rectal wall. If the rectal wall defect is extraperitoneal, high-risk patients who cannot tolerate an anterior resection. More
it may be left open to heal secondarily; however, many prefer to proximal lesions of the rectum that are not amenable to transanal
close all rectal wounds primarily.38 If the defect is intraperitoneal, excision or to endoscopic removal may be best treated by TEM,
closure is essential and is usually performed with a durable with low morbidity and mortality.
absorbable suture. Care must be taken to prevent stricture for- TEM begins with insufflation of CO2 into the rectum via a 4
mation.This is an especially critical concern if large or circumfer- cm operating rectoscope. Endoscopic instruments are then insert-
ential lesions are removed. In such cases, a sleeve closure with a ed and used under magnification to perform the local resection.
handsewn anastomosis after advancement of the proximal rectal The principles of resection are the same as for endoanal excision
wall to the more distal rectum is often the best option. Once the (see above).
defect is closed, the surgeon should perform proctoscopy to
ensure that the rectal lumen has not been compromised. Results. The largest review of TEM results to date included
137 patients and reported an 8% minor morbidity rate, a 2%
Results. The data currently available suggest that local recur- major morbidity rate, and a combined 5% recurrence rate for T1
rence rates are unacceptably high and that survival may be com- to T3 tumors over a period of 6 months.21 These results are
promised even when curative-intent local therapy is restricted to promising, but the follow-up period is too short for definitive con-
patients who have small, accessible intramural cancers with no clusions to be drawn.
signs of suspicious lymph nodes on preoperative imaging studies
and no unfavorable histologic features on the pretreatment biop- Posterior approach to local excision Local excision of
sy.The risk of local recurrence after local excision of selected, pre- rectal cancers can be performed via either a transsacral or a
sumably favorable lesions is 18% for T1 cancers and 37% to 47% transsphincteric approach with the patient in the prone jackknife
for T2 cancers.27-32 Salvage surgery is often possible if follow-up position. The Kraske procedure takes a transsacral approach. An
shows progression of pelvic cancer. No prospective studies direct- incision is made in the midline of the sacrum to expose the pos-
ly comparing the results of local excision with those of more rad- terior rectum by excising the coccyx and the last two sacral verte-
ical extirpative procedures have yet been done, and it is unlikely brae. Either a short segmental resection of the rectum with pri-

7. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 7
mary anastomosis or a proctotomy to expose and locally excise an of radical extirpative procedures. Headlights and lighted retrac-
intraluminal lesion is performed. In closing the rectal wall defect, tors allow visualization deep in the pelvis. Self-retaining retractors
care is taken not to compromise the lumen and create a stricture. (e.g., Balfour or Bookwalter retractors) are necessary. The St.
The York-Mason procedure takes a transsphincteric approach Mark pelvic retractor and the Wylie renal vein retractor facilitate
to expose the posterior rectum without resection of the sacrum. deep pelvic dissection. Long instruments are essential, and a vari-
Instead, the pelvic floor muscles are divided in the posterior plane, ety of staplers should be available.The presence of an experienced
and the resection then proceeds as in the Kraske procedure. The second surgeon or a highly trained assistant is invaluable.
sphincter muscles must be carefully reconstructed. Unfortunately,
morbidity is relatively high (e.g., a 20% incidence of fecal fistula) Intraoperative Decision Making
after both procedures.42 The surgeon always has a plan in place for the operation before
laparotomy, but it often happens that intraoperative findings
Fulguration (Electrocoagulation) necessitate a change in the plan. Thus, the surgeon must be flexi-
Fulguration, or electrocoagulation, involves destroying a cancer ble and willing to alter the planned operation in accordance with
with an electrode inserted into the wall of the lesion. As coagulum the situation.
builds up, it is debrided to allow additional coagulation until the After a midline incision is made, a thorough abdominal explo-
lesion and a circumferential rim of normal tissue have been ablat- ration is performed. At this point, the surgeon can confirm or
ed. The disadvantages of this procedure include postoperative revise the operative plan. Most often, the choice between a sphinc-
fever, the lack of a surgical specimen for staging, the requirement ter-sparing approach and a sphincter-sacrificing approach has
for repeated procedures, and the need to convert to more radical been made before operation, but for distal rectal cancer, it is not
procedures in a large number of patients.43 always possible to determine whether a restorative anastomosis is
Fulguration has often been used as curative-intent treatment, feasible until the rectum has been fully mobilized. In such cases,
with reported 5-year survival rates reaching 58%, but it is now the choice between sphincter-sparing and sphincter-sacrificing
used primarily for palliative purposes. Fulguration may be optimal proctectomy must be based on assessment of the adequacy of the
for patients with bulky bleeding rectal cancers who are too ill to distal margin [see Anterior Resection, Operative Technique, Step
undergo radical resection. 4, below].
Neoadjuvant therapy can reduce the size of a tumor so that it
Endocavitary Radiation (Papillon Technique) is amenable to low anterior resection instead of requiring APR.45
Endocavitary radiation involves high-dose contact (superficial) After full rectal mobilization, the surgeon assesses the possibility
radiotherapy delivered via a specially designed proctoscope. A of obtaining clean radial and distal margins, then decides to pro-
total radiation dose of 9 to 15 Gy is delivered in several sessions, ceed with either resection and anastomosis or APR.The desire to
usually over a period of 60 days. This modality is appropriate for perform an anastomosis must not be allowed to compromise
small noncircumferential lesions located within 10 cm of the anal oncologic outcome. Occasionally, circumstances arise in which
verge.The reported 5-year survival rate is 76%, with a local recur- the cancer is larger than anticipated or is extending into the
rence rate of 8.3% and a mortality of 7.7%.44 sacrum or other pelvic structures. In such circumstances, a more
extensive operation than was originally planned is appropriate if
curative resection can be achieved. Alternatively, the surgeon may
Radical Procedures be forced to perform a palliative operation.
OPERATIVE PLANNING ANTERIOR RESECTION
Preoperative Preparation Operative Technique
The possibility that a permanent or temporary stoma may be All curative-intent radical resections for rectal cancer use the
necessary should prompt a consultation with an enterostomal same technique for mobilizing the rectum and achieving proxi-
therapy nurse for the purpose of counseling the patient and mark- mal, lateral, and radial margin clearance. Anterior resections are
ing the abdominal wall at the appropriate location for a colosto- classified as high, low, or extended low, depending on the extent
my or temporary ileostomy [see 5:30 Intestinal Stomas]. of rectal mobilization and resection and on the level of the restora-
Generally, full mechanical and antibiotic bowel preparation is tive anastomosis.
performed on an outpatient basis the day before operation. An
antibiotic is administered intravenously just before induction of Step 1: mobilization of colon After abdominal exploration,
anesthesia. General anesthesia is employed, and an epidural the small bowel is packed into the upper abdomen, and the
catheter is often inserted to provide postoperative analgesia. If patient is placed in a slight Trendelenburg position. The rectosig-
there is a large, bulky rectal tumor or an associated inflammatory moid is retracted to the right, and the peritoneal attachments to
mass, ureteral stents may be placed to facilitate intraoperative the left of the sigmoid colon are incised along the avascular plane.
identification and protection of the ureters. A bladder catheter is The left ureter and gonadal vessels are identified and preserved by
inserted, and the patient is placed in a modified lithotomy posi- using sharp and gentle blunt dissection to separate the retroperi-
tion with the legs in stirrups. Pneumatic compression stockings toneal tissues from the sigmoid mesentery. The peritoneum is
and compression devices are used routinely, with or without incised along the left side of the descending colon as far as the
heparin. Digital rectal examination and rigid proctoscopy are per- splenic flexure. Adhesions to the spleen are divided, and the
formed to empty the rectum and reassess the rectal cancer. The splenic flexure is taken down. The colon mobilization extends
degree of involvement of the anal sphincter or other organs, the proximally to the left transverse colon.
level of the distal edge of the tumor, and the response of the tumor
to chemoradiation are noted. Step 2: ligation of inferior mesenteric artery The mobi-
A number of instruments are required to facilitate the conduct lized rectosigmoid is retracted anteriorly and to the left to expose

8. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 8
During the retrorectal dissection, the hypogastric nerves are
identified at the sacral promontory. These nerves descend in the
presacral space in a wishbone shape and must be preserved to
maintain postoperative sexual and urinary function. In the 1940s,
sexual dysfunction after proctectomy was reported in 95% of
male patients.46 If attention is given to nerve preservation during
proctectomy, however, 86% of male patients younger than 60
years retain sexual function.47 Posteriorly, the rectosacral fascia is
divided under direct vision, and the dissection proceeds distally to
the level of the coccyx. In mobilizing the rectum, it is helpful to
2
dissect in a posterior-to-lateral direction, with care taken to main-
tain the integrity of the endopelvic fascial envelope encasing the
1 bilobed mesorectum. The nervi erigentes are identified and pre-
served on the lateral pelvic sidewalls. When the middle rectal
artery is present as a distinct vessel, it can generally be fulgurated
during the lateral dissection; occasionally, however, the vessel is
large enough that ligation is necessary.
The final attachments are divided anterolaterally, and the ante-
rior pelvis is exposed. Exposure may be facilitated by reducing the
angle of the Trendelenburg position or even shifting the patient to
a reverse Trendelenburg position. The cul-de-sac is opened, and
Denonvillier’s fascia is incised. Deep pelvic retractors are placed
to protect the seminal vesicles and prostate (in males) or the vagi-
na (in females) as the dissection continues distally.
Step 4: assessment of distal margin At this point in the
operation, the rectum has been fully mobilized via the abdominal
approach, and the surgeon must decide whether a sphincter-pre-
serving anastomosis is possible or whether a sphincter-sacrificing
resection with construction of a permanent colostomy is neces-
sary. Because all radical resections for rectal cancer use the same
proximal, lateral, and radial dissection technique, the decision to
perform an anastomosis is based primarily on the ability to obtain
a clear distal margin.
There are two components to the distal margin: intramural and
mesorectal. At one time, a 5.0 cm intramural margin was recom-
Figure 2 Anterior resection. Illustrated is the tissue excised dur-
mended; however, subsequent studies demonstrated that a 2.0 cm
ing anterior resection. The surgeon may perform either a low li-
gation of the IMA (1), with preservation of the ascending branch,
intramural margin was adequate for curative resection. Margins
or a high ligation (2), where the IMA branches from the aorta. smaller than 1.0 cm were associated with increased local recur-
rence rates and decreased survival.48-50 Considerable emphasis is
now being placed on ensuring adequate mesorectal clearance. It
the inferior mesenteric artery (IMA). Transillumination of the was observed that local recurrence after radical resection correlat-
mesentery facilitates identification of an avascular space adjacent ed not just with the stage of the disease but also with the surgeon
to the IMA at the base of the mesentery. The peritoneum overly- performing the operation. Careful analysis suggested that some
ing this space is incised on either side of the IMA. Some surgeons surgeons did not remove the mesorectum completely and that
prefer a high ligation of the IMA where it branches from the aorta, tumor deposits in the mesorectum distal to the rectal cancer were
suggesting that this measure provides a more complete lymph responsible for high recurrence rates.51 Total mesorectal excision
node harvest. Others prefer a low ligation of the IMA just distal to (TME) was recommended as a means of minimizing local recur-
the left colic artery, suggesting that this approach ensures better rences. The current view is that a 5.0 cm mesorectal clearance is
blood supply to the proximal colon and prevents nerve injury at essential to prevent local recurrence in the pelvis.
the base of the IMA [see Figure 2]. At present, there is not enough If distal clearance (both intramural and mesorectal) is adequate
evidence to recommend one approach over the other. After liga- and if anal sphincter function justifies proceeding with an anasto-
tion of the IMA, it is convenient to divide the colon at the mosis, a right-angle clamp is placed distal to the tumor, and the
descending-sigmoid junction with a linear stapler. distal rectum is irrigated with sterile water or a tumoricidal agent.
A second right-angle clamp is then placed distally, and the rectum
Step 3: total mesorectal excision and preservation of is divided between the two clamps. This technique is used if an
autonomic nerves The rectosigmoid is retracted anteriorly open purse-string suture is to be placed in the distal rectal cuff. If
and inferiorly toward the pubis to expose the avascular plane pos- a double-stapled reconstruction is planned instead, a transverse
terior to the rectum. Sharp incision of this avascular plane while anastomosis (TA) stapler is placed distal to the right-angle clamp.
traction is placed on the rectosigmoid typically allows air to enter The stapler is fired and the rectum divided, leaving a closed rec-
the areolar tissue posterior and lateral to the rectum.The surgeon tal cuff for subsequent anastomosis.
follows the air, sharply dividing the loose areolar tissue posterior- The surgeon should then examine the resected specimen to
ly and laterally [see Figure 3]. assess the radial and distal margins and evaluate the integrity of

9. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 9
the mesorectal dissection. If the margins are inadequate or the stapler, without the anvil but with a trocar attachment, is inserted
mesorectum has been violated, local recurrence is a major con- through the anus and advanced proximally to the apex of the
cern.The treatment plan may have to be altered to reduce the risk closed stump [see Figure 4b].The stapler is opened to drive the tro-
of recurrence. car through the apex of the rectal stump adjacent to the staple
line. The trocar attachment is removed, and the mobilized
Step 5: creation of anastomosis Several reconstructive descending colon, with the anvil in place, is mated to the stapler
options are available for restoring bowel continuity after radical [see Figure 4c].The stapler is closed and fired, resulting in an end-
proctectomy. An end-to-end anastomosis is the traditional choice, to-end anastomosis [see Figure 4d].The integrity of the anastomo-
but alternative anastomoses are acceptable options in some situa- sis is assessed by insufflating air into the rectum with a procto-
tions [see Alternative Anastomoses, below]. scope while the anastomosis is under water [see Figure 5].
A straight or an end-to-side colorectal anastomosis (the Baker
technique) is appropriate after resection of most cancers in the Purse-string end-to-end anastomosis. The alternative to the dou-
proximal half of the rectum. The anastomosis can be handsewn, ble-stapled technique is to place purse-string sutures on both the
but most surgeons prefer to use a circular stapler. Functional proximal and the distal end of the bowel to be anastomosed. A
results after such proximal anastomoses are generally good. As continuous 2-0 purse-string suture is placed in the proximal end
surgeons developed reliable means of performing lower colorectal of the open rectal cuff, and a second purse-string suture is placed
and coloanal anastomoses, functional results were often subopti- in the descending colon [see Figure 6]. The circular stapler is
mal: patients reported urgency, frequency, seepage, and inconti- placed through the anus, and the anastomosis is fashioned and
nence.To overcome these problems, surgeons devised newer tech- checked for leaks as in the double-stapled technique.
niques aimed at increasing rectal reservoir capacity (e.g., the
colonic J pouch and coloplasty). Handsewn end-to-end anastomosis. The alternative to a stapled
anastomosis is a handsewn colorectal end-to-end anastomosis,
Double-stapled end-to-end anastomosis. The double-stapled which may be done in one or two layers with interrupted or con-
technique was devised to eliminate the need for a purse-string tinuous sutures. Handsewn colorectal anastomoses are typically
suture on the rectal cuff and to prevent fecal contamination. A performed from the abdominal field. It is often easiest to place all
purse-string suture is placed in the cut edge of the distal descend- of the sutures first, then “parachute” the proximal bowel down to
ing colon [see Figure 4a]. The anvil of a circular stapler is inserted the rectal cuff as the sutures are tied. The knots are generally tied
into the descending colon, and the purse-string is tied. on the inside to produce mucosal inversion.
The integrity of the stapled distal rectal stump is checked by Alternatively, if the distal cuff cannot be visualized from the
insufflating air into the rectum via a proctoscope while the rectal abdominal field, a handsewn anastomosis may be performed
stump is covered with saline. If no air leaks are noted, the circular transanally. This is generally more easily accomplished with the
patient in the prone jackknife position.
Alternative anastomoses. Three alternative reconstruction pro-
cedures have been devised to facilitate restoration of bowel conti-
Prostate nuity deep in the pelvis.The colonic J pouch and the Baker tech-
nique involve an end-to-side anastomosis, an approach that some
surgeons believe offers a more reliable blood supply than the tra-
Vesicle ditional end-to-end anastomosis. The colonic J pouch and colo-
plasty were designed to overcome the poor functional outcomes
frequently observed after straight coloanal or low colorectal anas-
Neurovascular tomoses by increasing the capacity of the neorectum.
Bundle A colonic J pouch is considered only for low anastomoses less
than 5 cm from the anal verge; if the procedure is performed more
proximally than 8 cm from the anal verge, it offers no functional
advantages over a straight colorectal anastomosis.52 Patients with
a colonic J pouch anastomosis 4 cm or less from the anal verge
demonstrate the greatest functional improvements.52
To create a colonic J pouch, the splenic flexure is mobilized to
provide adequate bowel length, and a well-vascularized segment
of the colon is selected for the pouch.The distal descending colon
is then folded into a J configuration [see Figure 7a]. It is essential
that the hook (i.e., the efferent limb) of the J be no longer than 5
to 6 cm, because longer limb lengths are associated with difficul-
ty in evacuation.53 A linear cutting stapler is inserted through a
colotomy on the antimesenteric surface of the inferior aspect of
the J pouch, then closed and fired. Once the linear staple line has
been checked for bleeding, the anvil of a circular stapler is placed
in the colotomy of the J pouch and secured in place with a 2-0
nonabsorbable suture.The J pouch–anal anastomosis is then per-
Figure 3 Anterior resection. Shown is a schematic depiction of formed with the circular stapler [see Figure 7b].
total mesorectal excision, highlighting the endopelvic fascial dis- Approximately 25% of patients are not suitable candidates for
section plane. a colonic J pouch because of a narrow pelvis or obesity.54 For

10. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 10
a b
c d
Figure 4 Anterior resection. Shown is a double-stapled end-to-end anastomosis. (a) The rectal
stump is closed with a linear noncutting stapler. A purse-string suture is placed around the colotomy,
and the anvil of the circular stapler is placed in the open end and secured. (b) The stapler, with the
sharp trocar attachment in place, is inserted into the anus, and the trocar is made to pierce the rectal
stump at or near the staple line, after which the trocar is removed. (c) The anvil in the proximal colon
is joined with the stapler in the rectal stump, and the two edges are slowly brought together. (d) The
stapler is fired and then gently withdrawn.
these patients, coloplasty is an alternative. Coloplasty is similar resection, the stapler anvil is inserted through the cut end of the
to Heineke-Mikulicz pyloroplasty. An 8 to 10 cm long antimes- descending colon. The trocar end of the anvil is brought out
enteric colotomy is initiated at a point 5 to 6 cm from the cut through the antimesenteric side of the colon approximately 3 to 4
end of the descending colon and extended proximally [see Figure cm from the distal cut end.The open end of the descending colon
8a]. The anvil of a circular stapler is placed in the colon and is closed. A circular stapler is then used to anastomose the side of
brought out the end of the colon before closure of the coloplas- the colon to the end of the rectum or the anal canal [see Figure 9].
ty. The colotomy is closed in a transverse direction, perpendicu-
lar to the antimesenteric border, with either absorbable sutures Troubleshooting
or a linear stapler [see Figures 8b and 8c]. An end-to-end anasto- Criteria for temporary fecal diversion The incidence of
mosis is then performed with the circular stapler [see Figure 8d]. anastomotic complications, including leakage, correlates with the
This procedure has not been accepted by most surgeons because level of the anastomosis: in general, the lower the anastomosis, the
of the long longitudinal colotomy along the antimesenteric higher the complication rate. Other factors, including previous
border. radiation therapy, immunosuppression, and underlying vascular
Although the end-to-side (Baker) anastomosis is not a new insufficiency or diabetes, may also increase the risk of anastomot-
technique, it is gaining popularity as an alternative to the more ic complications.
difficult and time-consuming pouch procedures. After the rectal The consequences of a leaking anastomosis remain a major

11. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 11
Figure 5 Anterior resection.
The integrity of the anastomosis
is assessed by holding it under
water and insufflating air via a
proctoscope while the bowel is
clamped.
source of morbidity and death after surgical resection of rectal ty of life after coloanal or colorectal reconstruction.The data indi-
cancer. Consequently, many surgeons perform routine temporary cate that the functional advantages of coloplasty and colonic J
fecal diversion for patients undergoing low anastomoses, especial- pouches are most discernible in the first 2 years after operation.
ly for those subjected to preoperative irradiation or receiving Measures of function—including urgency, frequency, nocturnal
steroid treatment. Loop ileostomy is the most commonly per- stooling, and continence—all show significant improvements in
formed temporary diversion, though some surgeons prefer proxi- patients who undergo colonic J pouch or coloplasty reconstruc-
mal loop colostomy [see 5:30 Intestinal Stomas]. Proximal fecal tion56; quality-of-life indicators and physiologic measures show
diversion does not protect against anastomotic leakage or prevent significant improvements as well.57 A 2002 trial from Singapore
anastomotic complications, but it does diminish the morbidity found the incidence of anastomotic leaks to be higher after colo-
resulting from leakage and reduce the likelihood of an emergency plasty reconstruction than after colonic J pouch reconstruction.58
operation.55 Our practice is to perform diversion for all patients Although this finding has tempered the enthusiasm for coloplasty
with a colorectal or coloanal anastomosis within 5 cm of the anus, reconstruction, the procedure remains a viable option in the
especially if they have undergone preoperative radiation therapy or patient with a narrow pelvis.
are immunosuppressed. The functional and surgical results seen with end-to-side anas-
tomoses are similar to those seen with colonic pouch anasto-
Outcome Evaluation moses.59 More data are needed to determine which reconstructive
Information is now available on functional outcome and quali- technique is best in which setting.
a b
Figure 6 Anterior resection. Shown is a purse-string end-to-end anastomosis. (a) Purse-string
sutures are placed on the rectum and on the proximal bowel. (b) The anvil of a circular stapler is
placed in the proximal bowel, and the stapler is placed through the anus. The anvil is joined with
the body of the stapler, and the stapler is fired to complete the anastomosis.

12. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 12
a more restorative anastomoses after radical resection of rectal can-
cer are based on data suggesting that APR offers no survival
advantage over sphincter-sparing procedures.17 Nevertheless, APR
is still performed in an estimated 30% to 60% of rectal cancer
b patients. A large review of 7,400 patients in the United States doc-
umented a 58% rate of APR performance.60 The reasons for this
persistently high APR rate are unclear.
Operative Planning
Synchronous APR APR, as the name suggests, may be
thought of as comprising two phases: an abdominal phase and a
perineal phase. The perineal phase of the operation may be done
synchronously with the abdominal phase, with the patient main-
tained in a modified lithotomy position. Proper positioning and
exposure are critical. The buttocks should be elevated with a pad
extending over the edge of the operating table and should be taped
laterally to provide good exposure of the perineum. The synchro-
nous approach may reduce operating time and is useful if the sur-
geon anticipates any difficulty in removing the rectum because of
lateral fixation.Working from above and below the area of fixation
simultaneously usually allows the proctectomy to be safely com-
pleted en bloc.This approach demands the presence of two expe-
rienced surgeons: performing the perineal phase with the patient
in the lithotomy position can be very demanding technically, espe-
cially if the patient is obese.
Figure 7 Anterior resection. Shown is the creation of a coloanal
anastomosis with a colonic J pouch. (a) The proximal bowel is sta- Sequential APR Alternatively, the perineal phase may be per-
pled closed and folded into a J shape, with the hook of the J being
formed with the patient in the prone jackknife position after com-
about 5 to 6 cm long. A colotomy is made in the base of the J, and
a J pouch is formed by inserting and firing a linear stapler. The
pletion of the abdominal phase.This approach is generally preferred
anvil of a circular stapler is placed in the base of the pouch. (b) because it provides excellent visualization for the perineal dissection
The J pouch is brought down to the anus, and the circular stapler and is especially useful if the tumor is fixed anteriorly. In addition,
is used to create the coloanal anastomosis. it has the advantage of providing more room for an assistant.
Operative Technique
ABDOMINOPERINEAL RESECTION
Steps 1 through 4 The abdominal phase of APR, including
APR involves en bloc resection of the rectosigmoid, the rectum, TME and nerve preservation, is identical to steps 1 through 4 of
and the anus along with the surrounding mesentery, mesorectum, an anterior resection [see Anterior Resection, Operative
and perianal soft tissues [see Figure 10]. Current efforts to perform Technique, above].
a b c d
Figure 8 Anterior resection. Illustrated is the coloplasty technique. (a) A longitudinal colotomy is made in
the antimesenteric side of the colon. (b) Sutures are placed on either side of the incision and used to apply
traction transversely. (c) The colotomy is closed in a transverse direction. (d) An end-to-end anastomosis to
the anus is performed.

13. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 13
is completed anteriorly, the specimen is inspected and sent for
pathologic examination. The pelvis is irrigated and hemostasis
secured. Some surgeons prefer to place a mobilized pedicle of
omentum into the pelvis to facilitate healing and reduce the risk of
small-bowel adhesions in the depths of the pelvis. The perineal
incision is closed in several layers with absorbable sutures. A trans-
abdominal drain is placed in the pelvis.
Step 6: creation of colostomy An end colostomy [see 5:30
Intestinal Stomas] is created before the perineal dissection if
sequential APR is performed but may be created simultaneously
with the perineal resection if a two-team synchronous APR is
performed. A 2 cm circular incision is made in the skin and sub-
cutaneous tissues overlying the premarked stoma site, which is
usually in the left lower quadrant of the abdomen. A cruciate
incision is made in the anterior fascia, the rectus abdominis is
split, and a second cruciate incision is made in the posterior fas-
cia. The mobilized colon is passed through this site and fixed to
the skin with 3-0 or 4-0 absorbable sutures. Because many
enterostomal therapists and patients find it easier to pouch an
elevated left-side colostomy, an eversion technique is used to
mature the stoma.
Figure 9 Anterior resection.
Depicted is a double-stapled end-
to-side colorectal anastomosis.
Step 5: perineal resection The perineal phase of APR is
performed with the patient in either the lithotomy or the prone
jackknife position, depending on whether the synchronous or the
sequential approach is followed.The perineum is exposed with the
aid of self-retaining retractors [see Figure 11]. The anus is closed
with a heavy purse-string suture to minimize the risk of spillage of
feces or tumor. An alternative means of accomplishing this goal is
to make the initial elliptical incision around the anus and then
approximate the perianal skin edges with sutures or Kocher
clamps. The elliptical incision should extend from the perineal
body anteriorly to the coccyx posteriorly. Laterally, the incision
should overlie the ischium. The incision is deepened into the
ischioanal fossa bilaterally with the electrocautery. The anococ-
cygeal ligament is divided posteriorly. The perineal surgeon can
then insert an index finger into the pelvis to guide division of pos-
terolateral soft tissue with the electrocautery. An appendectomy
retractor or springs may be used to improve retraction during
deeper dissection into the perineum. The dissection is continued
laterally and anterolaterally. When an ample aperture is created,
the proximal end of the specimen is passed between the coccyx
and the anus.
Traction is applied to the everted specimen to help the surgeon
develop the anterior dissection plane. In a female patient, an ante-
rior lesion may necessitate a posterior-wall vaginectomy to ensure
adequate margins. In a male patient, anterior dissection may lead
to injury to the urethra or excessive bleeding from the prostate
capsule; to minimize the risk of the former, it is helpful to palpate Figure 10 Abdominoperineal resection. Illustrated is the tissue
the Foley catheter during anterior dissection. Once the dissection excised during APR.

14. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 35 Procedures for Rectal Cancer — 14
a b c
d e
Figure 11 Abdominoperineal resec-
tion. Shown is the perineal phase of
APR. (a) An elliptical incision is made
around the anus. (b) Springs or retrac-
tors are used to provide exposure. (c)
Mobilization continues up to the trans-
versus perinei superficialis. (d) The le-
vator muscles are divided posteriorly.
(e) The specimen is delivered through
the wound posteriorly, and the anterior
dissection is complete.
OTHER RADICAL PROCEDURES traindication to sacrectomy because in this setting, the procedure
would result in unacceptably high morbidity and functional
Hartmann Procedure
sequelae. In the setting of advanced disease, the surgeon should
The Hartmann procedure [see 5:32 Procedures for Diverticular consider comfort care or additional adjuvant therapy before per-
Disease] is a seldom-used option that plays only a limited role in forming palliative exenteration. Other treatment modalities (e.g.,
the treatment of rectal cancer. It may be a good choice if the like- intraoperative radiotherapy, brachytherapy, and further chemora-
lihood of local recurrence is high (as with a perforated cancer) or diation) may be useful in this population.
if the patient manifests preexisting sphincter dysfunction. In these
situations, perineal dissection subjects the patient to unnecessary
morbidity. The distal rectum or anal canal is stapled closed and Outcome Evaluation
left in situ in the pelvis. The end colostomy is performed as in
APR. FOLLOW-UP REGIMENS
The primary purpose of surveillance after treatment of rectal
Pelvic Exenteration and Sacrectomy cancer is to detect early recurrence so that salvage therapy can be
The indications for pelvic exenteration are limited by the rela- instituted. A secondary purpose is to prevent development of a
tively high morbidity and mortality associated with the procedure. metachronous cancer by identifying and removing new polyps.
Pelvic exenteration for locally advanced or recurrent rectal cancer Symptoms of pain, pressure, weight loss, or bowel dysfunction
has been shown to have oncologic and palliative benefits. should be investigated. In addition to the physical examination,
Reported 5-year survival rates after pelvic exenteration for locally various laboratory studies, endoscopic procedures, and imaging
recurrent rectal cancer range from 20% to 30%.61 Primary modalities are used to detect or exclude recurrences. Although
advanced rectal cancer, however, is less often amenable to pelvic survival is improved after resection of recurrent lesions, especially
exenteration. in the setting of hepatic metastases, few data exist on the utility of
Pelvic exenteration may involve resection of the anus, the rec- close follow-up. Some studies have questioned the utility of fol-
tum, the bladder, the ureters, and the pelvic reproductive organs. low-up protocols.63,64 A survey of the American Society of Colon
Sacrectomy is sometimes necessary as well if the rectal cancer is and Rectal Surgeons and the Society of Surgical Oncology found
invading posteriorly.62 Reconstruction after these procedures that practice patterns were highly variable and that there was no
involves both fecal and urinary diversion; consequently, a multi- clear consensus on what constitutes appropriate follow-up after
disciplinary team is usually needed. treatment of rectal cancer.65
Detailed preoperative and intraoperative examination is essen- Most follow-up regimens include a routine history and physi-
tial to verify the presence of localized resectable disease before cal examination, carcinoembryonic antigen (CEA) testing, CT
proceeding with exenteration. If there is evidence of carcinomato- scanning, and routine colonoscopic evaluation.The roles of MRI,
sis, liver metastases, pelvic sidewall invasion, bilateral ureteral PET, and other imaging studies have not been defined. Our prac-
obstruction, or aortic node metastases, curative exenteration can- tice is to follow good-risk rectal cancer patients who have under-
not be performed. Invasion of the upper sacral vertebra is a con- gone curative-intent therapy every 4 months with ERUS and rigid