Rectum cancer treatment is changing day by day. The current standards of surgical treatment is discussed here. We practice in Shaheed Suhrawardy Medical College, Dhaka and BRB Hospitals Ltd, Dhaka

1. Standards of Surgical practice
for resectable rectal cancer
Presented by
Dr. Tariq Akhtar Khan
FCPS (Surgery), MS (Colorectal Surgery)
Assitant Professor (Colorectal Surgery), ShSMC, Dhaka.
Member, American Society of Colon and Rectal Surgeons (ASCRS)
Fellow and Life member, International Coloproctology Society (ISCP)
Life Member, Association of Colon and Rectal Surgeons of India, (ACRSI)

3. Shaheed Suhrawardy Medical College,
Dhaka
BRB Hospitals Ltd, Panthapath, Dhaka

4. Cancer of rectum
• Defined as cancer within 15 cm
of anal verge.
• 30% of all colorectal
malignancies in western
countries.
• Rectum cancer is more common
in this subcontinent than the
western

5. Non-peritonealized portion is covered with mesorectum

6. • In lower rectum a T3 tumour gone
through the wall of the bowel and
commonly will have an involved
margin at the level of sphincter
complex unless the rectum is excised
en block with the sphincter.

7. Primary tumour staging of rectum cancer (T)

12. • CT scan of whole
abdomen and chest
for distant
metastasis

15. /AR

18. Objectives of surgery
• Cure the patient
• If possible preserve normal bowel, bladder and sexual function

20. Distal spread
• For higher tumours:
• Distal mesorectal deposits upto 4 cm
is described. 5 cm lower edge
recommended
• For very low tumours:
• mesorectum has tapered and is no
longer an issue. In these cases distal
muscle tube excision is the issue.
• transmural: very uncommon for more
than 1 cm below distal palpable
margin of the tumour.
• Exception: poorly differentiated: 4.5
cm have occationally been reported.
So 5 cm distal clearance margin
should be considered. Otherwise 2
cm suffice.

21. Surgical classification of low rectal cancer

22. DRE
• Any palpably indurated tongue of tumour projecting downwards
towards the dentate line.
• Functional quality of anus.

23. Anastomosis after LAR/ULAR
• Stapled colorectal
• Handsewn coloanal anastomosis

24. Splenic flexure mobilisation
• High tie of IMA as the left coloc artery is too short
• Ligation of IMV below the lower border of pancreas as sigmoid
mesocolon is attached to the IMV.
• Unfolding of splenic flexure.

25. IMA ligation
• Flush on the aorta
• High ligation: 1-2 cm distally from its origin: is now recommended.
• Low ligation: below the take off of the left colic artery

26. Neorectal reservoir
• Increasingly recommended. Particularly important in elderly patients
in those with a slightly compromised anal function.
• 3 method
• J pouch
• Coloplasty
• Side to end anastomosis

27. Defunctioning
• Should be considered in all anastomosis where TME done
• Anastomotic leakage after low anastomosis is 10-28%.
• TME with stoma/ no stoma: leak rate10.3/28 %

28. Tumour disruption
• Adherent loop of intestine should be resected en block with the
primary tumour rather than pinched off.
• Maintain the integrity of the mesorectal envelope.
• Rough traction, blunt dissection, failure to identify and follow the
mesorectal fascia will contribute to disruption of the mesorectal
envelope.
• En-block hysterectomy and excision of posterior vaginal wall: when
the uterus or posterior vagina is involved.
• Cystectomy/ pelvic exenteration may require in an extensive anterior
tumour after neoadjuvant therapy

31. Implantation of viable cells
• Tripple stapling technique facilitates distal washout and eliminates
clamp slippage and faecal spillage.
• Tumour disruption is discussed earliers

32. APR/APE indication
• Cancer involving the sphincter or so near to it./ Anal canal
• Functional result of retorative surgery likely to be so poor that a
colostomy would provide better QoL. Sphincter/ LAR syndrome
• Potential complications of attempts to restore intestinal continuity
are prohibitive, particularly in the frail and elderly.
• Consider neoadjuvant in cases that require an APE.

38. • Compared with LTME, RTME was associated with lower conversion
rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004),
• lower positive rate of circumferential resection margins (CRM) (2.74
% vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04),
• lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02,
0.41]; P = 0.002).

39. • no significant differences between the two groups in
• Operation time, estimated blood loss,
• recovery outcome, postoperative morbidity and mortality,
• length of hospital stay,
• number of lymph nodes harvested, distal resection margin (DRM), proximal
resection margin (PRM), and
• local recurrence
• Conclusions: RTME is safe and feasible and may be an alternative
treatment for RC.

41. • Only randomised controlled trials (RCTs) comparing LTME and OTME
• mean conversion rate of 14.5% (range 0% to 35%) in the lap group.
• laparoscopic and open TME had similar effects on five-year disease-
free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943).
• local recurrence and overall survival were similar, (local recurrence:
OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI
0.87 to1.52).

42. • number of resected lymph nodes and surgical margins were similar
between the two groups.
• For the short-term results,
• length of hospital stay was reduced by two days (95% CI -3.22 to -1.10)
• the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17
to -0.54).
• 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1).
• fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding
complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.
• There was no clear evidence of any differences in quality of life after LTME
or OTME regarding functional recovery, bladder and sexual function.
• The costs were higher for LTME with differences up to GBP 2000 for direct
costs only.

43. Local excision
• Traditional criteria:
• <10cm from dentate line
• <4 cm in diameter
• <40% of rectal circumference
• Not applicable for TEMS. It is for TAE.

46. Preparation for surgery
• Bowel preparation. Still recommended.
• Antibiotic prophylaxis
• Comorbidity and nutritional evaluation. Adressed accordingly
• Thromboprophylaxis.

47. ELD
• Extended lateral lymph node dissection
• Controversial topic

48. Palliation
• For whom curative resection is not possible
• Complete but palliative resection of the primary tumor leads to a
better quality of life and prevents many of the distressing symptoms:
• Obstruction
• Bleeding
• Pain
• Stoma/Temporary stent