[Surgery treatment of rectal cancer]

Surgical resection is the only curative procedure for carcinoma of the rectum. Heald's development of total mesorectal excision has made it the standard approach for mobile, non-fixed tumors; it permits optimal local control with less than 10% local recurrence at five years and minimizes nerve damage and genito-urinary complications. Although initial short-term results of laparoscopic approaches are very promising, the final role of laparoscopy has not yet been established. Neo-adjuvant radiotherapy should be proposed for locally advanced (T3, T4, and/or N+) tumors of the low and mid-rectum. Radiochemotherapy coupled with intersphincteric dissection offers hope for sphicter-sparing extirpation of even the lowest of rectal cancers. Local resection through a trans-anal approach may be considered for small (<3 cm.), mobile, well-differentiated tumors lying within 8 cm. of the anal verge if rectal echo-endoscopy shows an in-situ tumor or a T1 lesion with no evidence of lymphadenopathy. Future strategies may enlarge the indications for local resection if and when radiochemotherapy can achieve a complete local response (tumor sterilization).