Surgical treatment of rectal cancer: State of the art and future perspectives

Background: Surgical management is the primary treatment of potentially curable rectal cancer. In most cases, this involves resection of the primary tumour and regional lymph nodes. However, treatment of rectal cancer patients may vary from local excision in carefully selected patients with limited carcinomas to multimodality management for advanced rectal cancers. The objective in all cases is to maximize both oncological and functional results. The purpose of this article is to provide an overview of state of the art surgical treatment of primary rectal cancer as well as a discussion of selected current controversies. Methods: Extent of resection, operative techniques such as local excision, coloanal anastomosis with or without a colonic pouch reservoir, need for a defunctioning colostomy, laparoscopic rectal surgery, and quality of life after surgery for rectal cancer are discussed. Results: In rectal cancer patients, a total mesorectal excision is the standard procedure. A local excision may be performed for favourable T1 cancers. Low or ultralow resections with coloanal anastomoses show the same oncological results as abdominoperineal excisions. A colonic pouch significantly improves postoperative function in patients with sphinctersparing resections. However, postoperative sphincter function might be impaired and further studies are necessary to determine quality of life in these patients. Prospective studies should be performed to compare oncological outcome after laparoscopic and open resections. Conclusions: Surgical treatment of rectal cancer depends on localization, extent, and histology of the tumour. Preoperative education of patients and extensive discussion of potential postoperative problems are crucial for determining which patient benefits most from which type of surgery.