[Rectum carcinoma. Optimizing therapy by deep resection or excision]

Abdominoperineal excision of the rectum has been the surgical treatment of choice for rectal cancer of the middle and lower third for decades. However, subsequent to technical developments, particularly stapling instruments, sphincter saving procedures such as low anterior or intersphincteric resection superseded abdominoperineal excision in the majority of tumors of the middle and even lower third of the rectum. Within the last seven years (1990-1997), 253 patients with distal rectal cancer underwent surgery--in 204 patients surgery was carried out for the cure of malignancy, whereas in 49 patients surgery was performed for palliation. In the meantime, the rate of abdominoperineal excision with permanent stoma was steadily decreased from 25% (1990-1993) to 9% (1994-1997). Concerning oncologic quality, sphincter saving resections showed evidence that cure rates (3- and 5-year survival) were not compromised by these techniques; conversely, sphincter saving resections offered oncologic cure rates superior to abdominoperineal excision of the rectum. Complete lymphadenectomy with high ligation of the inferior mesenteric artery and total mesorectal excision (TME) are fundamental components of this approach. Moreover, the adverse effects of a permanent colostomy and the consecutively diminished quality of life following abdominoperineal excision can be avoided in approximately 80% of cases. In conclusion, at present 80-85% of rectal carcinomas of the middle or lower third can be surgically treated by sphincter saving low resections without compromising oncologic radicality.