Exfoliated tumour cells and locally recurrent colorectal cancer

The presence of intraluminal viable exfoliated tumour cells has been demonstrated in patients with colorectal cancer. Several non-randomised studies found a significant reduction of the recurrence rate after the intraoperative luminal instillation of cytotoxic agents, as compared with "historical" patient series. Antiseptic solutions, e.g. sodium hypochlorite and povidone-iodine, were reported to be "cancericidal" for exfoliated cancer cells in vitro. A survey held among Belgian surgeons practising colorectal cancer surgery revealed that 78% of them never use any agent during surgery. Only a minority performs pre-resectional luminal instillation-mostly to treat the distal (low) anastomotic level: 14% in patients with rectal cancer and 7% in patients with colon cancer. About 8% of the surgeons only perform peritoneal/pelvic lavage at the end of the procedure. This is in strong contrast with surgical practice in the UK. It seems reasonable to advocate intra-operative pre-resectional bowel washouts with cytotoxic agents besides other measures to avoid recurrence, e.g. the no touch isolation technique with early division of the vascular supply, wide excision of the mesenterium, avoidance of iatrogenic tumour perforation, "en bloc" resection if adjacent organs are invaded, adjuvant radio- and chemotherapy.