Current Surgical Strategies in the Management of Rectal Cancer

Purpose of Review The surgical approach to rectal cancer has become significantly more complex with the introduction of neoadjuvant therapies and organ preservation strategies. Optimal radiological imaging in association with relevant clinical findings provides critical information for final surgical management decision. The present review focuses on the surgical alternatives available in different clinical scenarios for the management of rectal cancer. Recent Findings Most of evidence for surgical management of rectal cancer is provided by non-randomized studies. However, a few randomized clinical trials have attempted to address the optimal surgical approach for total mesorectal excision. In addition, recent randomized trials have also contributed to the understanding of the role of organ-preserving strategies among patients with excellent response to neoadjuvant treatment. Finally, one randomized Japanese study has provided oncological evidence in favor of prophylactic lateral node dissection among these patients. Summary Radical proctectomy with total or partial mesorectal excision is the standard procedure for most patients with primary rectal cancer. Optimal approach for this procedure remains controversial. The decision between sphincter-preservation strategies and abdominal perineal resections should take into account the radiological and clinical findings. More recently, organ-preserving strategies including transanal local excisions may be used in select patients with early-stage disease or among patients undergoing neoadjuvant treatment strategies after significant primary tumor regression. Extended procedures including lateral pelvic side lymphadenectomies and exenterative procedures should be done selectively and in highly specialized centers.