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Rectal cancer: Surgical techniques

Authors: Ronald Bleday, MD, David Shibata, MD

Section Editor: Martin Weiser, MD
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2018. | This topic last updated: Jun 13, 2017.

INTRODUCTION — Surgery is the cornerstone of curative therapy for rectal adenocarcinoma [1]. Depending upon the clinical stage, size, and location of the primary tumor,
a rectal cancer can be treated with either local or radical excision. A local excision is usually performed transanally. A radical excision is performed transabdominally with
either a sphincter-sparing procedure or an abdominal perineal resection. Rectal cancers that have invaded adjacent organs may require a multivisceral resection.

In this topic, we review various surgical techniques that are used to treat rectal cancer. A stepwise approach to selecting the appropriate surgical technique is outlined in an
algorithm and described in another topic (algorithm 1). (See "Overview of the management of rectal adenocarcinoma", section on 'Management according to initial clinical
stage'.)

The surgical anatomy of the rectum, general principles of rectal surgery for cancer, choices of operative approaches (open versus laparoscopic), and the treatment of
primary rectal squamous cell carcinomas are discussed in other topics. (See "Rectal cancer: Surgical principles" and "Clinical features, staging, and treatment of anal
cancer", section on 'Rectal squamous cell cancers' and "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy".)

LOCAL EXCISION — Local excision is an appropriate therapy for patients who have early-stage rectal cancer without high-risk features and for those with more advanced
diseases but who are medically unfit for radical surgery (algorithm 1).

Local excision permits removal of both the tumor and adjoining rectal tissue in one specimen (ie, full thickness excision) without tumor fragmentation, which permits
pathologic assessment of inked margins, histologic differentiation, vascular involvement, and depth of invasion. However, it does not excise or stage mesorectal lymph
nodes and therefore could miss nodal metastasis or tumor cell deposits in the mesorectum. (See "Overview of the management of rectal adenocarcinoma", section on
'Clinical/pathologic T1N0' and "Overview of the management of rectal adenocarcinoma", section on 'Clinical T2N0'.)

Criteria for local excision — Patients with an early rectal cancer that meets all of the criteria below are eligible for local excision [2-7]:

● Superficial T0 or T1 rectal cancer (table 1).

● Tumor less than 3 cm in diameter.

● Tumor involves <30 percent of the bowel lumen circumference.

● Tumor is mobile and nonfixed.

● Able to achieve clear margins with local excision.

● Favorable histologic features based upon biopsy (ie, well- to moderately differentiated cancer, no lymphovascular or perineural invasion).

● No radiographic evidence of metastatic disease to regional nodes (N0).

● Patient compliant with aggressive postoperative surveillance.

Patients with more advanced diseases (eg, cT2 or higher) may also be treated with local excision after sufficient counselling, if they [8,9]:

● Have medical comorbidities that preclude any transabdominal surgery.

● Refuse any transabdominal surgery.

● Have a short life expectancy due to metastatic disease.

Patients with more advanced disease (T2 or greater) may benefit from neoadjuvant therapy prior to local excision and may require further surgery or adjuvant treatment
after local excision, depending upon the final pathologic staging. (See "Overview of the management of rectal adenocarcinoma", section on 'Clinical T2N0'.)

Techniques of local excision — Rectal cancer can be locally excised by transanal excision (TAE) or transanal endoscopic surgery (TES) techniques. The choice of
technique is dependent upon tumor location and surgeon expertise, which are further discussed elsewhere. (See "Transanal endoscopic surgery (TES)".)

Transanal excision (TAE) — Traditionally, low rectal cancers were most often excised with the TAE technique [6,10]. In contemporary practice, TAE is less commonly but
still performed to locally excise very distal lesions in the anal canal or when transanal endoscopic surgery equipment or expertise is not available.

The disadvantage of TAE alone is the high recurrence rate, ranging from 0 to 31 percent, which could potentially compromise cure [11-13]. In a prospective study of 291
patients with T1M0 rectal cancer within 15 cm from the anal verge, patients treated with a TAE without neoadjuvant therapy were more likely to have macroscopic tumor
remnants compared with patients undergoing a major rectal resection (6/35 versus 0/226 patients) [6]. Patients treated with a TAE had a significantly higher five-year local
recurrence rate (12 versus 6 percent) and lower five-year survival rate (70 versus 80 percent) and five-year disease-free rate (64 versus 77 percent).

Transanal endoscopic surgery (TES) — TES is an emerging technique that offers transanal access to resecting early rectal cancer [14-26]. It can be performed with one
of three platforms, transanal endoscopic microsurgery (TEM), transanal endoscopic operation (TEO), or transanal minimally invasive surgery (TAMIS). (See "Transanal
endoscopic surgery (TES)".)

Compared with TAE, TES offers improved visualization, exposure, and access. As a result, TES was associated with lower rates of specimen fragmentation, positive
margins, and local recurrences than TAE [27].

Posterior excisions (rarely used) — Rectal cancers in the mid or upper rectum that were unreachable by TAE were excised with one of the posterior techniques.
However, these techniques have largely been supplanted by TES because of higher morbidity [28,29]. They remain a salvage option for treating local recurrences in the
presacral space following an abdominal perineal resection, or for treating fistulas arising after a low anterior resection or prostatectomy [30].

● The transsphincteric (York-Mason) procedure – The transsphincteric (York-Mason) procedure approaches the rectum posteriorly by dividing the puborectalis, levator
ani, and external anal sphincter muscles. Following resection of the tumor, the rectum and the posterior incision are closed primarily [31].

● The transsacral (Kraske) procedure – The transsacral (Kraske) procedure mobilizes the rectum transabdominally, then delivers the mobilized rectum posteriorly via a
defect created by resecting the coccyx and dividing the levator ani muscle [32]. After the lesion is excised, the rectum and the posterior incision are closed primarily
[28].

Outcomes of local excision — Outcomes for local excision are dependent upon the T stage of the rectal cancer. For T1N0 tumors, local excision alone was associated with
few local recurrences (8 percent) and good survival (84 percent) that remained durable with long-term follow-up (7.1 years) [33]. For T2N0 cancers, survival outcomes were
also reasonable (88 percent at three years) when patients are given preoperative chemoradiation therapy prior to local excision [8].

Current guidelines from the United States [34] and Europe [35,36] recommend local excision of T1N0 rectal cancers with good pathologic features, including (see
"Transanal endoscopic surgery (TES)", section on 'T1N0 rectal cancer'):

● Moderately to well-differentiated tumor

● Absence of lymphovascular invasion

● Absence of perineural invasion

Regardless of whether neoadjuvant therapy is administered, local excision should only be performed for T2N0 rectal cancers in patients who are unfit for transabdominal
surgery or as a part of clinical trials. Local excision as the sole surgical treatment for ≥T2N0 rectal cancer is still investigational out of concerns for micrometastasis in the
mesorectum and residual disease in the excision bed. (See "Transanal endoscopic surgery (TES)", section on 'T2N0 rectal cancer'.)

Treatment options after local excision — Following local excision, patients may or may not require further surgery or medical treatment depending upon the final
pathological staging. Those with favorable histologies (pT1 or less, negative margins, moderate to well differentiation, no lymphovascular or neural invasion) do not require
any further treatment and can be observed with intensive endoscopic surveillance.

Patients with unfavorable histologies (pT2 or greater, or presence of positive margins, poor differentiation, or lymphovascular/perineural invasion) should be advised to
undergo radical transabdominal surgery, or else the local recurrence rate can be as high as 26 to 47 percent [33,37-39]. Those who are unable or unwilling to undergo
additional surgery are treated with adjuvant chemoradiation therapy followed by close observation for recurrence (algorithm 1). (See "Overview of the management of
rectal adenocarcinoma", section on 'Clinical/pathologic T1N0'.)

Favorable histology — Local excision for T1 rectal cancer without high-risk features on histology can offer durable local control and good survival. In one study, only 6
percent of patients with completely excised low-risk T1 cancers developed a local recurrence at a median of 20 months (range 4 to 36 months) [40]. The 10-year disease-
free survival and overall survival were 92 and 98 percent, respectively.

Local recurrences are typically seen within the first three years after local excision. Thus, intensive endoscopic surveillance is recommended during the first three to five
years after a local excision. Local recurrences after five years have been reported, but it is unclear whether they represent true local recurrences or new primaries [41,42].
Thus, endoscopic surveillance should be continued after five years, albeit less frequently. (See "Overview of the management of rectal adenocarcinoma", section on 'Stage I
disease'.)

Unfavorable histology — Patients with unfavorable histologies (pT2 or greater disease, positive margins, poor differentiation, lymphovascular or perineural invasion)
should undergo transabdominal surgery (completion total mesorectal excision [TME]), preferably in one to eight weeks. For patients who have received neoadjuvant
radiation therapy, we delay further surgery until the site of local excision has completely healed.

For patients who are offered but refuse immediate reoperation, the alternative is adjuvant chemoradiation therapy followed by close surveillance [43]. However, such
patients can expect to have more recurrences because adjuvant therapy is not as effective in clearing micrometastasis in the mesorectum or residual disease in the
excision bed. In a 2016 meta-analysis of 19 observational (including two comparative) studies, local excision followed by adjuvant chemoradiation therapy was associated
with higher local recurrence rates than local excision followed by TME for pT1 (10 versus 6 percent), pT2 (15 versus 10 percent), and pooled pT1-2 rectal cancer (14 versus
7 percent) [44]. The distant recurrence rates were not different for pT1-2 diseases (6 versus 6 percent). Should patients recur, they will require salvage surgery.

Immediate reoperation for unfavorable histology after local excision has been associated with better survival than salvage surgery performed after a local recurrence. In
one study, patients who underwent immediate reoperation had fewer local recurrences (8 versus 37 percent), developed fewer metastatic diseases (10 versus 23 percent),
and had better 10-year survival (89 versus 72) compared with those who chose to forego immediate reoperation [40].

SPHINCTER-SPARING PROCEDURES — Patients with invasive rectal adenocarcinomas who are not candidates for local excision should undergo radical transabdominal
surgery (algorithm 1). A sphincter-sparing resection is preferred if a negative distal margin can be achieved. An abdominal perineal resection (APR) is required if an
adequate distal margin cannot be obtained. (See "Overview of the management of rectal adenocarcinoma", section on 'Clinical T3-4, N0-2 or T2, N1-2' and "Rectal cancer:
Surgical principles", section on 'Distal margin'.)

Criteria for sphincter-sparing resection — Patients with a rectal cancer that meets all of the criteria below should undergo a sphincter-sparing resection:

● Invasive rectal cancer cT2-4 (table 1).

● A negative distal margin can be achieved. (See "Rectal cancer: Surgical principles", section on 'Distal margin'.)

● Adequate presurgical anorectal sphincter function.

Techniques of sphincter-sparing resection — A sphincter-sparing procedure entails partial or total resection of the rectum (ie, low anterior resection [LAR]) followed by a
colorectal or coloanal anastomosis to reestablish intestinal continuity.

The techniques of laparoscopic and robotic proctectomy are also discussed in another topic. (See "Minimally invasive techniques: Left/sigmoid colectomy and
proctectomy", section on 'Laparoscopic/robotic proctectomy'.)

Resection — LAR involves removal of the sigmoid colon and rectum to a level where the distal margin is free of cancer, followed by a primary anastomosis between the
descending colon and the rectum (colorectal anastomosis) or anal sphincter (coloanal anastomosis). The splenic flexure should be mobilized for the descending colon to
reach the deep pelvis for the anastomosis (figure 1 and figure 2).
 Intersphincteric resection (ISR) for low rectal cancer — For a highly select group of patients with low-lying rectal cancer in whom a standard LAR would not yield an
adequate distal margin, proctectomy with intersphincteric resection (ISR) may be a viable alternative to abdominoperineal resection. Ideal candidates are generally younger
with strong presurgery sphincter strength and bowel function. Also, a rectal protocol magnetic resonance imaging (MRI) scan should be performed prior to surgery to
confirm that the outer border of the internal sphincter and the muscularis propria are clear of cancer.

ISR extends the surgical margin further distally by separating the internal and external anal sphincters and removing the internal sphincter partially or completely.
Anatomically, the internal anal sphincter is the continuation of the muscular layer of the rectum. Following a proctectomy with total mesorectal excision and ISR, intestinal
continuity is restored with a coloanal anastomosis (with a colonic J pouch, whenever feasible). The external anal sphincter is preserved during ISR to ensure reasonable
functional outcomes (ie, continence) after surgery [45].

In a systematic review of 14 retrospective studies including 1289 patients, a margin-negative resection was achieved with ISR in 97.0 percent of patients [46]. The operative
mortality and morbidity rates were 0.8 and 25.8 percent. After a median follow-up of 56 (range 1 to 227) months, the mean local recurrence rate was 6.7 (range 0 to 23)
percent, and the overall and disease-free survival rates were 86.3 and 78.6 percent, respectively. Following surgery, most studies reported a significant reduction in resting
anal pressure but not squeeze pressure. Functionally, fecal urgency was present in up to 58.8 percent of patients [45]; the mean number of bowel movements in a 24-hour
period was 2.7 [46].

Total mesorectal excision — For rectal cancer, LAR must be performed with a total mesorectal excision (TME) to ensure negative circumferential radial margins and
complete removal of all draining lymphatics. The principles and techniques of TME are discussed elsewhere. (See "Rectal cancer: Surgical principles", section on 'Total
mesorectal excision'.)

An example of the laparoscopic approach to a sigmoid colectomy and LAR can be found in the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
video library.

An example of the laparoscopic nerve sparing proctectomy with mesorectal excision for rectal cancer can also be found in the SAGES video library.

Anastomosis — Following LAR, nearly one-half of patients may develop problems with their bowel function, such as fecal urgency, frequency, clustering, or incontinence,
due to a loss or reduction in rectal capacity [47]. Those undergoing a colorectal anastomosis are less likely to have problems because they typically have sufficient rectal
reserve. Patients undergoing coloanal anastomosis, however, often complain of frequent or fragmented stool pattern for at least one year postoperatively. Several
techniques of coloanal anastomosis have been developed to improve their postsurgical bowel function, including colonic J-pouch reservoir, side-to-end anastomosis, and
transverse coloplasty. (See "Low anterior resection syndrome (LARS)".)

For patients undergoing a coloanal anastomosis, a colonic J-pouch with a 4- to 6-cm reservoir is the best option but is only feasible in approximately 60 percent of patients
due to technical limitations (eg, narrow pelvis, bulky anal sphincters, insufficient colon length, or diverticulosis) [48]. A side-to-end anastomosis with a terminal side
segment of 3 cm is the second best option, which can be performed in most nonobese patients. Transverse coloplasty can be achieved in over 95 percent of patients but
has a higher leak rate and worse functional outcomes than the first two options [47,49].

Colonic J-pouch reservoir — Constructed in the shape of the letter "J" (figure 3), a colonic J-pouch reservoir provides a larger neorectal reservoir compared with the
straight coloanal anastomosis [50]. The distal 8 cm of the colon is used to create a pouch with an undistended volume of 60 to 105 mL, an optimal capacity that facilitates
evacuation without compromising defecation [51-55]. Larger reservoirs result in difficulties evacuating the colon; smaller reservoirs are associated with incontinence and
frequent bowel movements.

Outcomes of the colonic J-pouch procedure have been studied extensively [49,56-59]. A meta-analysis of randomized trials showed that a colonic J-pouch led to better
functional outcomes than the straight coloanal anastomosis for the first eight months after surgery [49]. Specifically, a colonic J-pouch resulted in fewer bowel movements
per day (mean difference -2.85) and less antidiarrheal medication use (27 versus 45 percent). At two years, the differences were not present any longer due to bowel
function adaptation. Compared with a straight coloanal anastomosis, a colonic J-pouch procedure does not carry any higher mortality or morbidity (eg, anastomotic leak or
stricture, bleeding, reoperations) [49,56-60].

An example of the laparoscopic approach to a low anterior resection and transanal mucosectomy with construction of a J-pouch can be found in the SAGES video library.

Side-to-end reservoir — Approximately 5 to 25 percent of patients with rectal cancer are not candidates for a colonic J-pouch due to technical reasons (eg, inability
to sufficiently mobilize the colon to construct a low anastomosis, bulky colon, or a narrow pelvis) [59]. For those patients, a side-to-end coloanal anastomosis can be used
to increase the neorectal capacity. After resection of the rectum, the side, rather than the end, of the colon is anastomosed to the anal canal, making a "T"-shaped coloanal
anastomosis (figure 4). A side-to-end coloanal anastomosis requires fewer staple lines than the colonic J-pouch procedure.

An example of the laparoscopic approach to a total mesorectal excision with intersphincteric dissection and coloanal anastomosis in ultra-low rectal cancer can be found
in the SAGES video library.

Transverse coloplasty reservoir — Transverse coloplasty is another rarely used technique to increase the neorectal capacity after LAR.

Transverse coloplasty augments the neorectal reservoir by making an 8- to 10-cm longitudinal colotomy between the colonic tenia beginning approximately 4 to 6 cm
proximal to the distal end of the mobilized descending colon and reapproximating the incision transversely [59]. The distal end of the colon is anastomosed to the anal
sphincter (coloanal anastomosis).

Because of its mixed functional results, transverse coloplasty is mostly of historic interest and only performed when patients are not candidates for either a colonic J-
pouch procedure or a side-to-end coloanal anastomosis due to technical limitations (eg, a narrow pelvis) [48,59,61-66].

Temporary diverting stoma — A temporary diverting stoma is used to protect an anastomosis if the anastomosis is low (<5 cm), under tension, or if the intraoperative
leak test is positive [67]. Additionally, we have a low threshold for using a temporary diverting ostomy in patients who have had preoperative chemoradiation and in those
who are on immunosuppressive therapy, such as glucocorticoids [68,69].

Several meta-analyses suggested that a defunctioning stoma reduced the rates of both clinically relevant anastomotic leakages and reoperations [68,70]. A prospective
survey of 60 patients with a temporary stoma after rectal cancer surgery found good global quality-of-life scores [71].

Outcomes of sphincter-sparing resection — Sphincter-sparing procedures and APR have similar local recurrence rates of 6 to 31 percent [46,72,73]. Lower recurrence rates
are generally associated with the use of meticulous surgical techniques (eg, achieving adequate margins, performing total mesorectal excision) and/or adjuvant
chemoradiation therapy. (See "Rectal cancer: Surgical principles", section on 'Principles of surgical resection' and "Neoadjuvant chemoradiotherapy, radiotherapy, and
chemotherapy for rectal adenocarcinoma" and "Adjuvant therapy for resected rectal adenocarcinoma in patients not receiving neoadjuvant therapy".)

ABDOMINAL PERINEAL RESECTION — Traditionally, abdominal perineal resection (APR) was the gold standard for treating low-lying rectal cancers against which
sphincter-sparing procedures and local excision were compared. With the advent of better surgical techniques and equipment (eg, staplers) as well as neoadjuvant therapy,
APR has been gradually replaced by sphincter-sparing procedures. However, patients with disease involvement of the anal sphincter musculature or rectovaginal septum,
as well as those with poor preoperative continence or diarrheal disorders, are still best treated with an APR. (See "Overview of the management of rectal adenocarcinoma",
section on 'Locally advanced, unresectable, bulky tumors, extensive nodal disease' and "Overview of the management of rectal adenocarcinoma", section on 'Management
of locally recurrent disease'.)

Criteria for abdominal perineal resection — Patients with an invasive, cT2-4 rectal cancer (table 1) who also meet one of the criteria below should be treated with an APR
[74]:

● A negative distal margin of 1 cm cannot be achieved with any of the sphincter-sparing procedures. (See 'Sphincter-sparing procedures' above.)

● Locally advanced low-lying rectal cancer.

● Locally recurrent low-lying rectal cancer (as a salvage procedure).

● Poor presurgical anorectal function.

Techniques of abdominal perineal resection — An APR entails en bloc resection of the sigmoid colon, rectum, and anus, followed by construction of a permanent
colostomy. The techniques of APR are discussed elsewhere. (See "Abdominal perineal resection (APR): Open technique".)

Outcomes of abdominal perineal resection — Progressively lower surgical anastomoses are associated with commensurate decline in anorectal function, characterized by
increased stool frequency, more incontinence and perianal irritation, decreased stool and flatus discrimination, more incomplete evacuations, and decreased rectal
compliance [75]. Poor anorectal function results in poor quality of life (QOL). In one prospective study of QOL after rectal cancer surgery, patients who had an anastomosis
within 5 cm of the anal verge had significantly worse QOL compared with those who underwent an APR [76].

According to several studies, long-term QOL after APR was similar to QOL after sphincter-sparing procedures [76-81]. QOL was not adversely affected by adjuvant radiation
therapy after an APR [82].

MULTIVISCERAL RESECTION — A multivisceral resection includes the resection of the rectum along with one or more adjacent organs invaded by the rectal cancer. It is
required for curative resection of T4 rectal cancers. (See "Overview of the management of rectal adenocarcinoma", section on 'Locally advanced, unresectable, bulky
tumors, extensive nodal disease' and "Overview of the management of rectal adenocarcinoma", section on 'Management of locally recurrent disease'.)

Criteria for multivisceral resection — Multivisceral resection is a potentially morbid procedure that is only used when a less radical procedure would not suffice in one of
two scenarios [7,83-85]:

● Locally advanced rectal cancer involving adjacent organs or bony structures (T4) (table 1)

● Locally recurrent rectal cancer (as a salvage procedure)

Techniques of multivisceral resection — A multivisceral resection involves resection of the rectum with one or more of the adjacent pelvic organs or bony structures. It can
be performed as a total or partial (modified) pelvic exenteration depending upon the extent of the disease.

A total pelvic exenteration removes all of the pelvic organs, including the rectum, bladder, and internal reproductive organs (ie, prostate and seminal vesicles in males or
uterus, ovaries, and vagina in females) [86,87]. A partial pelvic exenteration can be anterior, posterior, supralevator, or composite, depending upon the organs or structures
resected. A multivisceral resection for rectal cancer most often requires a posterior or a supralevator partial pelvic exenteration.

The techniques of multivisceral resection are discussed in detail elsewhere. (See "Exenteration for gynecologic cancer", section on 'Operative technique'.)

Outcomes of multivisceral resection — In a retrospective review of 1741 patients with T4M0 rectal cancer, patients treated with a multivisceral resection had a better
overall five-year survival than those treated with a standard colorectal resection (35 versus 28 percent) [88]. Other studies also showed that multivisceral resection can be
performed with low mortality (range 0 to 8 percent) but high morbidity (range 26 to 61 percent) and high reoperation rates (20 to 30 percent) [86,89-97].

Compared with patients undergoing multivisceral resection for recurrences, patients undergoing multivisceral resection for locally advanced primary rectal cancer have
better disease control (89 versus 38 percent) and survival (43 to 66 percent versus 1 to 8 percent) [86,87,91,92].

Multivisceral resection is typically used as a part of multimodality therapy for treating locally advanced or recurrent rectal cancer. Adjuvant therapy for treating locally
advanced or recurrent rectal cancer is discussed separately. (See "Neoadjuvant chemoradiotherapy, radiotherapy, and chemotherapy for rectal adenocarcinoma" and
"Adjuvant therapy for resected rectal adenocarcinoma in patients not receiving neoadjuvant therapy".)

SURGICAL PALLIATION — For patients who present with a recurrent or metastatic rectal cancer that is unresectable, the goal of surgery is to relieve obstruction and/or
control hemorrhage, rather than to cure cancer. Up to 20 percent of patients with colorectal cancer present as emergencies, for whom surgical palliation can be achieved
by endoluminal stenting, proximal diversion, or one of the nonresectional procedures such as fulguration or endocavitary radiation. However, fulguration and endocavitary
radiation are rarely performed in modern practice.

● Endoluminal stenting – An endoluminal expanding stent can act as a "bridge" to allow decompression and bowel preparation before definitive surgery, or as a
palliation in nonsurgical candidates. Stenting should not be performed for distal rectal cancer because stents deployed in the low rectum can cause tenesmus and
pain. The techniques of endoluminal stenting are discussed elsewhere. (See "Enteral stents for the management of malignant colorectal obstruction".)

● Proximal diversion – Proximal diversion is performed to relieve intestinal obstruction in patients whose rectal cancer is not amendable to endoluminal stenting. A loop
ostomy with a distal limb is preferred in those with complete obstruction to permit retrograde distal decompression. The techniques of proximal diversion are
discussed elsewhere. (See "Overview of surgical ostomy for fecal diversion".)

● Fulguration – Fulguration (electrocoagulation) is performed by inserting an electrode into the wall of the rectal cancer to destroy the cancer along with a
circumferential rim of normal tissue. While it was once used as a curative procedure, it is generally reserved for palliative purposes, especially for locally recurrent
cancers, and is rarely used in contemporary practice.

Fulguration may be used in patients who have bulky bleeding rectal cancers but are too ill to undergo more extensive procedures. The disadvantages of fulguration
include postoperative fever, inability to stage the patient due to the lack of a surgical specimen, and need for repeated procedures. Conversion to a resection procedure
may be required if fulguration fails to control the patient's symptoms.

● Endocavitary radiation by contact and/or interstitial brachytherapy – Endocavitary radiation entails the placement of a high-dose-rate radioactive source (eg, Iridium-
192) directly into the rectum through a special proctoscope. A retrospective review of 102 patients identified a local control rate of 83 percent for T1 cancers and 38
 percent for T2 cancers in patients treated by contact therapy or interstitial brachytherapy, respectively [98]. Endocavitary radiation therapy is associated with a high
local recurrence rate (22 percent in one study) [99].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Colorectal cancer".)

SUMMARY AND RECOMMENDATIONS

● Local excision is an appropriate therapy for patients who have early-stage rectal cancer (≤cT1) without high-risk features and may be offered to those with more
advanced diseases (≥cT2) but are medically unfit for radical transabdominal surgery after sufficient counselling. It is typically performed with transanal endoscopic
surgery or, less frequently, with transanal excision. (See 'Local excision' above.)

● Following local excision, those with favorable histologies (≤pT1, negative margins, no lymphovascular, perineural invasion, or poor differentiation) do not require any
further treatment and can be observed with intensive endoscopic surveillance. Patients with unfavorable histologies (≥pT2, positive margins, poor differentiation,
perineural invasion, or lymphovascular invasion) should undergo radical transabdominal surgery. Those who are unable or unwilling to undergo additional radical
surgery are treated with adjuvant chemoradiation therapy followed by close observation for recurrence. (See 'Local excision' above.)

● Patients with invasive rectal adenocarcinomas, who are not candidates for local excision, should undergo radical transabdominal surgery. A sphincter-sparing
resection is preferred if a negative distal margin can be achieved. An abdominal perineal resection (APR) is required if an adequate distal margin cannot be obtained or
if the patient has poor presurgical anorectal function. (See 'Sphincter-sparing procedures' above and 'Abdominal perineal resection' above.)

● For patients undergoing a coloanal anastomosis following rectal cancer excision, a colonic J-pouch with a 4- to 6-cm reservoir is the best option but is not feasible in
all patients due to technical limitations (eg, narrow pelvis, bulky anal sphincters, insufficient colon length, or diverticulosis). A side-to-end anastomosis with a terminal
side segment of 3 cm is the second best option, which can be performed in most nonobese patients. (See 'Anastomosis' above.)

● A multivisceral resection is required for patients with T4 rectal cancer that invades adjacent organs or bony structures or as a salvage procedure for locally recurrent
rectal cancer. A total or partial pelvic exenteration is required to achieve a curative resection in such patients. (See 'Multivisceral resection' above.)

● Patients who present with an obstructing rectal cancer are typically palliated by endoluminal stenting or proximal diversion. (See 'Surgical palliation' above.)

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96:430.

Topic 15311 Version 21.0

GRAPHICS

Algorithmic approach to management of rectal adenocarcinoma

This is an overview of our approach to the management of newly diagnosed nonmetastatic rectal adenocarcinoma. It should be used in conjunction with other UpToDate content on rectal adenocarcinoma.

EUS: endoscopic ultrasound; MRI: magnetic resonance imaging; CT: computed tomography; LAR: low anterior resection; APR: abdominal perineal resection.
* CT of the torso (CT of the chest and abdomen if pelvic MRI has been done, and CT of the abdomen, chest, and pelvis if no pelvic MRI) is recommended for all except those with clinical T1N0 cancers with favorable histologic fact
¶ A malignant polyp can be managed endoscopically if the following criteria are met:
The polyp is considered to be completely excised by the endoscopist (ie, pT1) and is submitted in toto for pathological examination.
The polyp is fixed and sectioned so that it is possible to accurately determine the depth of invasion, grade of differentiation, and completeness of excision of the carcinoma.
The cancer is not poorly differentiated.
There is no vascular or lymphatic involvement.
The margin of the excision is not involved. Invasion of the stalk of pedunculated polyp, by itself, is not an unfavorable prognostic finding, as long as the cancer does not extend to the margin of stalk resection.
No invasion beyond submucosa.
Not a sessile polyp.
Δ Cases with all of the following features are amenable to local excision; just because the tumor is amenable to local excision does not mean it is the procedure of choice. The best choice may be a transabdominal surgery, espec
consider (addressed in the discussion):
 Superficial T1 cancer, limited to the submucosa.
No radiographic evidence of metastatic disease to regional nodes.
Tumor <3 cm in diameter.
Low risk of developing positive regional nodes (well-differentiated, no lymphovascular or neural invasion).
Involves <30% of the circumference of the lumen.
Mobile, nonfixed.
Margins clear (>3 mm).
Compliance with appropriate postoperative surveillance.
◊ In most centers, all patients who undergo neoadjuvant chemoradiotherapy are offered adjuvant chemotherapy due to difficulty in assessing nodal status in the treated surgical specimen. Postoperative chemotherapy is omitted f
chemoradiotherapy.
§ Patients who refuse surgery or are considered poor surgical candidates after chemoradiotherapy may be managed by full-thickness local excision after chemoradiotherapy. Highly selected patients who appear to have a comple
local excision but should understand that transabdominal surgery represents a standard approach in this setting. More extensive residual disease at the time of local excision should prompt reconsideration for transabdominal su
¥ Some guidelines suggest that local resection be limited to T1 tumors with limited submucosal excision only. Refer to UpToDate text on the overview of treatment of rectal cancer.

Graphic 108222 Version 5.0

Colorectal cancer TNM staging AJCC UICC 2017

Primary tumor (T)

T category T criteria

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ, intramucosal carcinoma (involvement of lamina propria with no extension through muscularis mucosae)

T1 Tumor invades the submucosa (through the muscularis mucosa but not into the muscularis propria)

T2 Tumor invades the muscularis propria

T3 Tumor invades through the muscularis propria into pericolorectal tissues

T4 Tumor invades the visceral peritoneum, or invades or adheres to adjacent organs or structures

T4a Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of
inflammation to the surface of the visceral peritoneum)

T4b Tumor directly invades or adheres to adjacent organs or structures

Regional lymph nodes (N)

N category N criteria

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 One to three regional lymph nodes are positive (tumor in lymph nodes measuring ≥0.2 mm), or any number of tumor deposits are present and all identifiable
lymph nodes are negative

N1a One regional lymph node is positive

N1b Two or three regional lymph nodes are positive

N1c No regional lymph nodes are positive, but there are tumor deposits in the:
Subserosa
Mesentery
Nonperitonealized pericolic, or perirectal/mesorectal tissues

N2 Four or more regional nodes are positive

N2a Four to six regional lymph nodes are positive

N2b Seven or more regional lymph nodes are positive

Distant metastasis (M)

M category M criteria

M0 No distant metastasis by imaging, etc, no evidence of tumor in distant sites or organs. (This category is not assigned by pathologists.)

M1 Metastasis to one or more distant sites or organs, or peritoneal metastasis is identified

M1a Metastasis to one site or organ is identified without peritoneal metastasis

M1b Metastasis to two or more sites or organs is identified without peritoneal metastasis

M1c Metastasis to the peritoneal surface is identified alone or with other site or organ metastases

Prognostic stage groups

When T is... And N is... And M is... Then the stage group is...

Tis N0 M0 0

T1, T2 N0 M0 I

T3 N0 M0 IIA

T4a N0 M0 IIB

T4b N0 M0 IIC

T1-T2 N1/N1c M0 IIIA

T1 N2a M0 IIIA

T3-T4a N1/N1c M0 IIIB

T2-T3 N2a M0 IIIB

T1-T2 N2b M0 IIIB

T4a N2a M0 IIIC

T3-T4a N2b M0 IIIC

T4b N1-N2 M0 IIIC

Any T Any N M1a IVA

Any T Any N M1b IVB

Any T Any N M1c IVC

TNM: tumor, node, metastasis; AJCC: American Joint Committee on Cancer; UICC: Union for International Cancer Control.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Graphic 111438 Version 3.0

Mobilization of the splenic flexure

This figure depicts mobilizing the splenic flexure, one of the challenging components of a left colectomy.
The dissection progresses from the midtransverse colon medially to distally, a technique particularly
helpful in obese patients or in settings when the splenic flexure cannot be safely approached and
mobilized laterally.

Graphic 81638 Version 2.0

Dissection of the left mesocolon from Gerota's fascia

The splenic flexure is mobilized by dissecting the left mesocolon from Gerota's fascia.

Graphic 56301 Version 3.0

Colonic J-pouch

A colonic J-pouch is created by folding the distal colon on itself, followed by division of the septum
and creation of a reservoir using a linear stapler. The pouch is suitable for either transanally
sutured or stapled reconstructions.

Graphic 82078 Version 8.0

Side-to-end coloanal anastomosis

A side-to-end anastomosis is created by joining the side of the distal colon to the end of the rectum
or anus, in the shape of the letter "T."

Graphic 101412 Version 2.0

Contributor Disclosures
Ronald Bleday, MD Nothing to disclose David Shibata, MD Nothing to disclose Martin Weiser, MD Nothing to disclose Wenliang Chen, MD, PhD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and
through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate
standards of evidence.

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