Modern management of rectal cancer: a 2006 update

The goal of this review is to outline some of the important surgical issues surrounding the management of patients with early (T1/T2 and N0), as well as locally advanced (T3/T4 and/or N1) rectal cancer. Surgery for rectal cancer continues to develop towards the ultimate goals of improved local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary, and sexual function. Information concerning the depth of tumor penetration through the rectal wall, lymph node involvement, and presence of distant metastatic disease is of crucial importance when planning a curative rectal cancer resection. Preoperative staging is used to determine the indication for neoadjuvant therapy as well as the indication for local excision versus radical cancer resection. Local excision is likely to be curative in most patients with a primary tumor which is limited to the submucosa (T1N0M0), without high-risk features and in the absence of metastatic disease. In appropriate patients, minimally invasive procedures, such as local excision, TEM, and laparoscopic resection allow for improved patient comfort, shorter hospital stays, and earlier return to preoperative activity level. Once the tumor invades the muscularis propria (T2), radical rectal resection in acceptable operative candidates is recommended. In patients with transmural and/or node positive disease (T3/T4 and/or N1) with no distant metastases, preoperative chemoradiation followed by radical resection according to the principles of TME has become widely accepted. During the planning and conduct of a radical operation for a locally advanced rectal cancer, a number of surgical management issues are considered, including: (1) total mesorectal excision (TME); (2) autonomic nerve preservation (ANP); (3) circumferential resection margin (CRM); (4) distal resection margin; (5) sphincter preservation and options for restoration of bowel continuity; (6) laparoscopic approaches; and (7) postoperative quality of life.