Indications and surgical alternatives for palliation of rectal cancer

The goals of palliation of rectal cancer are relief of disabling symptoms and maximizing quality of life. Surgical intervention is appropriate in specific situations, where the selected procedure is chosen based on likelihood of achieving these goals, balanced against morbidity and recognition of the patient's limited life expectancy. Locally unresectable rectal cancer may be treated by transanal procedures where obstruction is the major feature; techniques used include local resection, self-expanding metal stents, and laser debulking of tumor where the rectal lumen is compromised. As well, colostomy may be used with or without external beam radiation therapy but is preferred when transanal techniques are unsuitable. Resective techniques such as anterior proctosigmoidectomy and anastomosis, Hartmann's resection, or abdominoperineal rectal excision are preferred in fit patients where local clearance is possible and longevity expectations are deemed reasonable--e.g., six months or more. Decisions for performing restorative procedures are based on risk assessment for anastomotic leak and quality of anal function. In rare cases, palliative exenteration is an option, although controversial. Recognition of contraindications to resection will minimize the risk of disabling or lethal complications of these procedures.