Rectal Cancer: a Review

Rectal Cancer: A Review

1. General Background

Colorectal cancer (CRC) is a major health problem affecting both developed and undeveloped countries. Approximately 1 million new cancers occur worldwide and CRC remains in the top three of all cancer deaths(1). By location, two-thirds of the colorectal cancer cases occur in the colon and one-third in the rectum (2). The incidence in Africa is low, but unfortunately so is survival, mostly due to late presentation(3). Prevalence is more difficult to estimate in under-developed countries due to lack of a cancer registry in these countries. Some, like Zambia, are trying to establish such a registry at the current time. In both developed and under-developed countries CRC is of public and political concern. The aim of this review is to discuss important issues surrounding rectal cancer, including its surgical and medical management. For a comprehensive review on colon cancer, please see our published review on that topic http://www.ptolemy.ca/members/current/ColonC/ .

2. General Anatomy

The rectum is a continuation of the colon preceded by the sigmoid colon and terminating in the anal canal. It has two major curves, one at the proximal end and one at the distal end, bending backward and forward respectively. It extends about 2-3cm below the coccyx before it ends at the anal canal above the dentate line. The total length of the rectum is about 12-15 cm and the diameter is similar to that of the sigmoid. The rectum is not covered by taenia coli, in contrast to the sigmoid colon. There are 3-4 transverse folds, known as the valves of Houston, which consist of circular muscle fibers and have a role in retaining fecal matter in the rectum. Peritoneum covers the upper one third of the rectum, while the remaining portion remains extraperitoneal. The anterior peritoneal space is also called the pouch of Douglas and is a well known area of metastatic disease (Bloomer's shelf).

The arteries that supply the rectum include the superior, middle and inferior hemorrhoidal arteries which are branches from the inferior mesenteric, hypogastric and internal pudendal arteries, respectively. The superior hemorrhoidal artery divides into two branches that run down the lateral aspect before entering the rectum and supply up to the point of the internal sphincter where they anastomose with the middle and inferior hemorrhoidal arteries. The veins start off as the hemorrhoidal plexus and form trunks that run parallel to the arteries. Veins include the superior, middle and inferior hemorrhoidal veins with the anal canal being drained by the middle and inferior veins. The superior hemorrhoidal drains into the inferior mesenteric vein and the middle and inferior vein drain into the hypogastric vein that drains directly into the inferior vena cava. This difference in drainage accounts for differences in metastatic patterns, mainly portal versus systemic, respectively.

Lymphatics lie within the mesorectum. Proximal rectum lymphatic drainage is mostly through the Para-aortic nodes, while the distal rectum drains through the Para-aortic and the internal iliac system that ends up in the superficial inguinal region.

Innervation is both from sympathetic and parasympathetic nerves. Postganglionic sympathetic fibers come from the pelvic plexus (T12-L3) that is adherent to the pelvic sidewalls and lateral stalks. It receives its branches from the presacral plexus, which condenses into the left and right hypogastric nerves. Failure to preserve at least one of these nerves during dissection results in ejaculatory retrograde dysfunction in men. The pelvic parasympathetic nerves arise from S2 to S4 and through the pelvic plexus innervate the prostate, urethra and urinary bladder. Disruption of these can result in bladder and sexual erectile dysfunction which have been reported in up to 40% of malignant resection cases.

The main function of the rectum is to retain fecal matter. When stool enters the rectum the anorectal inhibitory reflex is triggered resulting in voluntary contraction of the external sphincter. It also triggers the rectocolic reflex allowing relaxation of the rectum and subsequent filling of the rectum. Muscles aiding in continence usually extend just proximal to the dentate line. For anatomy of the anal canal, please see our review on common anorectal disorders http://www.ptolemy.ca/members/current/anorectal/ .

3. Epidemiology/Etiology

Both the epidemiology and etiology of colorectal cancer are discussed in detail in our review on colon cancer. As such only a general overview is given here. In the United States each year about 42,000 individuals are diagnosed with rectal cancer, and 8,500 die of this disease (4). As with colon cancer, Western nations tend to have a higher incidence than Asian and African countries and incidence peaks in the sixth and seventh decades. In spite of the low incidence of cancer in Africa, survival rates are very low, not exceeding 55% at 5 years in Zimbabwe. This has been explained by poor distribution of resources among other reasons (3,5). These figures are expected to worsen in the future due to increased urbanization, adoption of the Western diet and relatively poor funding for cancer-related conditions in Africa.

Etiology is again similar to colon cancer and is multifactorial in origin. It includes environmental factors, such as diet, and a large genetic component. In the West about two thirds of cases are sporadic and develop in people with no specific risk factors; while the other one-third occur in people with either a positive family history or a personal history of colorectal cancer or polyps. A smaller percentage occur in people with genetic predispositions, such as hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis (FAP).

4. Relevant Pathophysiology

As with colon cancer over 70% of rectal cancers, regardless of etiology, arise from adenomatous polyps. The adenoma-carcinoma sequence discussed in the colon review takes place over 7 to 15 years. Since 1932, when Sir Cuthbert Dukes described his staging system, many advances have been made especially in the genetic and molecular fields. Mutations discovered since then include point mutations in the K-ras proto-oncogene; hypomethylation of DNA, leading to gene activation; loss of tumor-suppressor gene (the adenomatous polyposis coli (APC) gene on 5q21 and colorectal cancer (DCC) gene on 18q) and mutations in the p53 tumor-suppressor gene (6). These alterations then result in mucosal proliferation forming a polyp and finally carcinoma. Distinct mutations associated with familial colorectal cancer-associated syndromes include APC for FAP, MLH1, MSH2, MSH6, and PMS mutations for HNPCC.

Molecular pathology can also help predict the response of a tumor to therapy. The presence of p53 has been associated with an increased likelihood of resistance to radiotherapy, while expression of p21 gene makes it more sensitive (7). Likewise, increased thymidylate synthase activity increases resistance to 5-FU, while microinstability increases sensitivity (8).

Invasiveness is a very important indicator of prognosis, defined as extension of malignant cells through the muscularis mucosa. Haggitt and colleagues proposed a classification system according to the depth of invasion for pedunculated polyps: Level 0 (no invasion of muscularis mucosa), Level 1 (invasion through muscularis mucosa limited to head of polyp), Level 2 (invasion through muscularis mucosa limited to neck of polyp), Level 3 (invasion through muscularis mucosa in any part of the stalk), and Level 4 (invasion into the submucosa of the native bowel wall below the polyp). These levels correlate with degree of lymph node metastases with level 0-3 being associated with less than 5% risk and level 4 has a 10-25% risk of associated metastases. Pathologists use the classification systems of Dukes or TNM classification (37). The TMN system is similar to that for colon cancer. (See Tables 1 & 2) With rectal cancer there may be early lymphatic spread into the nodes of the mesorectal fascia or hematogenous spread, mainly to the liver or lungs.

Table 1 TNM

T (assesses the primary tumor)
X	Primary tumor cannot be assessed
O	No evidence of primary tumor
Is	Carcinoma in situ: intraepithelial or invasion of the lamina propria
1	Tumor invades submucosa
2	Tumor invades muscularis propria
3	Tumor invades through the muscularis propria into the subserosa, or into nonperitonealized pericolic or perirectal tissues
4	Tumor directly invades other organs or structures, and/or perforates visceral peritoneum
N (assesses the regional lymph nodes)
X	Regional nodes cannot be assessed
0	No regional lymph node metastasis


1	Metastasis in 1 to 3 regional lymph nodes
2	Metastasis in 4 or more regional lymph nodes
M (assesses distant metastasis)
X	Distant metastasis cannot be assessed
0	No distant metastasis
1	Distant metastasis

Table 2 AJCC and Duke Staging

AJCC	Duke		TNM
Stage 0	NA	Tis	N0	M0
Stage I	A	T1	N0	M0
	B1	T2	N0	M0
Stage IIA	B2	T3	N0	M0
Stage IIB	B3	T3	N0	M0
Stage IIIA	C3	T1	N1	M0
	C3	T2	N1	M0
Stage IIIB	C2-3	T3	N1	M0
	C2-3	T4	N1	M0
Stage IIIC	C1-3	any T	N2	M0
Stage IV	D	any T	any N	M1

5. Diagnosis

In general rectal cancer often causes no specific symptoms until it reaches an advanced stage. As such screening is the primary modality of diagnosis (9). Symptoms most often occurring with rectal cancer include hematochezia, pelvic pain, change in bowel habits including obstruction and tenesmus. Symptoms can give a surgeon information regarding both the tumor itself and location . For example, tenesmus occurs especially with tumors located low in the rectum or potentially with sphincter invasion, and pain with evacuation suggest lower rectum tumor (as tumors higher up are often painless). Symptomatic patients often have a worse prognosis as a higher percentage are in later stages of development (10). All patients also should undergo a complete personal and family history.

The digital rectal examination (DRE) is the most important diagnostic and easiest tool for rectal cancer. Up to 80% of rectal cancers are palpable (11). The site of rectal cancers are measured in cms. from the anal verge. The area up to about 8cm above the dentate line can be assessed for size, ulceration, lymph nodes and possible fixation (12). Sphincter tone can also be assessed, which is important for the decision on possible sphincter-sparing surgery. It is important to assess the location of tumor in relation to the puborectalis and sphincteric complex when deciding on the suitability of a sphincter-sparing procedure. Other modalities include fecal occult blood testing (FOBT), sigmoidoscopy, rigid proctoscopy, double contrast barium enema (DCBE), positron emission tomography (PET), magnetic resonance imaging (MRI), computed tomography (CT).

The gold standard is colonoscopy. One needs to evaluate the entire rectum and colon up to the cecum as 5% of patients have synchronous tumors. All these modalities are discussed in detail in our review of colon cancer. Briefly, rigid proctoscopy is excellent for direct visualization and accurate determination of the distance of the tumor from the anal verge. Colonoscopy and enema studies allow one to not only visualize the tumor, but evaluate for synchronous lesions. Endorectal ultrasound and MRI can evaluate for local invasion for T-staging as well as predict localized lymph node metastases. PET has an evolving role, primarily in the setting of recurrent disease.

In general once the diagnosis of rectal cancer has been made, one needs to establish the extent of disease both locally and wide spread. Depth of tumor penetration, lymph node involvement and distant metastases are crucial in deciding if surgery can be curative or not and if neoadjuvant therapy is necessary.

For this workup endorectal ultrasound, MRI, as well as CT are the modalities most often used. Endorectal ultrasound (ERUS), although operator dependent, and MRI are the most accurate for determining the extent of local spread (13); while CT is the most common modality for distant metastases.

In general, labs values that should be checked are the same for colon cancer and rectal cancer. They include cell blood count (CBC), chemistry panel, coagulation parameters (PT/PTT/INR), carcinoembryonic antigen (CEA), CA19-9, and liver function tests (LFTs). Again one needs to be aware that CEA is not very reliable as it is also elevated in pancreatic and hepatobiliary disease (14) and that LFT's can be normal even in the presence of hepatic metastases. Genetic counseling should be considered in the presence of very young patients or in the setting of a strong familial history or known CRC syndromes.

Although the primary histological type of rectal cancer is adenocarcinoma, differential diagnosis should include but is not limited to squamous cell carcinoma, lymphoma, carcinoid, sarcoma, hemorrhoids, diverticulitis, infection, inflammatory bowel disease, or foreign bodies. Thus full evaluation and biopsy of all suspected lesions is mandatory prior to embarking on a therapeutic regimen.

Approximately 20% of patients with newly diagnosed rectal cancer have distant metastases at the time of diagnosis (15). This number is higher in under-developed countries where screening capabilities are limited. Due to the dual venous return, distal spread is often located either in the liver or lung - depending if the tumor is located in the upper or lower rectum respectively. As stated, metastastic evaluation often includes CT scan, although positron emission tomography (PET) with fluorine-18-labelled deoxyglucose has been shown in some studies to be more sensitive than CT for both hepatic and extrahepatic disease (16). Unfortunately this mode of investigation is not available in many hospitals in developing countries, and the information it provides in the setting of primary disease may not often change the management. Its use is increasingly popular in the setting of recurrent disease or when it is difficult to distinguish inflammatory conditions from recurrent cancer.

In summary, FOBT in patients with lower GI symptoms cannot be overemphasized in the diagnosis of rectal cancer. Moreover DRE and proctoscopy are mandatory to avoid confusing rectal cancer with internal hemorrhoids. Finally in view of the paucity of sophisticated investigations, a CxR and abdominal ultrasound may serve to identify distant metastases and guide operative management in the advanced cases seen in developing countries.

6. Surgical Management

There have been great advances in the surgical technique for rectal cancer. The main goals of surgery are local and regional control with high cure rate. Local recurrence has decreased significantly over the last decade especially with the introduction of total mesorectal excision (TME) (17). Pre-operative bowel decontamination is preferred in all the following procedures to reduce infectious complications, though some evidence indicates enemas may be used alone prior to surgery (18). Overall the surgeon has three major curative options from which to choose - depending on the location and extent of the tumor: local excision (LE), low anterior resection (LAR), and abdominal perineal resection (APR).

Transanal local excision is best for T1N0, and possibly for high-risk patients with T2 tumors that are well or moderately differentiated (though becoming less accepted due to high local recurrence). The two main methods of surgical therapy via a local approach are the transanal local excision (TAE) and excision performed with transanal endoscopic microsurgery (TEM). In each of these cases, a full thickness rectal wall resection of the mass and surrounding margin is performed. TAE is limited mostly by the distance of the lesion from the anal verge, which also depends in part on patient body habitus, and is usually not recommended for tumors located above 8-10 cm. Techniques, such as intussusception of the rectum, can aid in allowing access to more proximal lesions that would not otherwise be reachable and permit a standard TAE. Size is another determinant of the ability to undergo LE. Some authors cite 3-4 cm as the maximal dimension that should be considered with this approach, as larger lesions resected with this method lead to higher failure rates. On the other hand, TEM requires additional training and special equipment. Despite its increased specialization, it does have the advantages of better visualization, and the ability to access more proximal lesions that would otherwise not be amenable to a transanal approach.

In general, local excision has minimal morbidity associated with it, but does have higher recurrence rates compared to radical resection. As lymph nodes are not excised, good patient selection is imperative. Even with good patient selection, local recurrence can be as high as 29% for T1 and 50% for T2 tumors (19). As stated, a complete full-thickness excision of the tumor down to the perirectal fat is performed. Circumferential margins should be 1cm or greater. Primary closure of the resulting defect with sutures is standard practice, although it may not always be necessary for those lesions below the peritoneal reflection. It is important to keep the specimen properly oriented and marked to determine appropriate margins. If the margins are found to be positive for tumor then additional resection is necessary or a radical resection should be considered. Tumor characteristics, location or size may exclude it from re-excision and necessitate a more radical resection.

Transanal endoscopic microsurgery can be an option if standard local excision is not possible. With this operation a 25cm scope is used to excise tumors in the upper rectum. It allows for full thickness excision under direct vision. Selection criteria are the same as for transanal excision (20).

More radical resection is necessary for most T2, and definitely T3, T4 and node positive disease. For those patients with locally advanced (T3/T4) and node positive disease, the addition of neo-adjuvant chemoradiation therapy has become a common approach and will be discussed below. Radical resection procedures include abdominoperineal resection (APR) and low anterior resection (LAR). Although the APR removes the entire anal canal with permanent stoma while the LAR restores continuity, the rectal dissection remains the same for each procedure. Standard surgical approach involves a total mesorectal excision (TME), which was described originally in 1982 by Heald and colleagues (21). It involves removal of the mesorectum in the mesorectal plane by sharp dissection (instead of the traditional blunt maneuvers) and removes all lymphatics and vascular supply, along with the mass and surrounding bowel. As fascial planes are followed, pelvic autonomic nerves are spared. This dissection is facilitated by the use of cautery. In practical terms TME involves removal of the rectum and the fat and fascia around it so that the specimen excised appears like "a smooth sausage". The proximal margin is based on the blood supply to the rectum with standard ligation of the inferior mesenteric artery, distal margins of at least five centimeters for upper and mid rectal cancer and 1-2 cm for low rectal cancer. Radial spread has important prognostic implications and incomplete excision results in higher local recurrence rates. TME improves radial resection and local recurrence rates are reduced. Complications can include anastomotic leak, wound infection, alterations in bowel movements, urinary incontinence, impotence, and impaired sexual activity. Overall 5-year survival has been reported as high as 80% (22).

Abdominoperoneal resection was first described in 1908 by Ernest Miles. The rectum and corresponding mesorectal fascia are mobilized down to the sphincters through an abdominal approach, while the remaining sphincter complex and surrounding tissue are removed via a perineal excision (23). Positioning may be either in the lithotomy position throughout or placing the patient in prone-jackknife for the perineal portion of the operation. With a traditional open approach, a midline incision is preferred because of the placement of a colostomy. As with all abdominal surgeries, one should begin with initial inspection of the entire abdomen paying special attention to the liver as well as the presence of any lymphadenopathy. Proceed to expose the pelvic structures by placing traction on the lower sigmoid and incise the lateral attachments of the rectosigmoid. As this is an avascular plane, no bleeding should occur. Do the same on the right and anterior in the rectovesical recess and posteriorly, with careful attention to identify and preserve left ureter. Some surgeons prefer to begin with a medial approach by incising the medial peritoneum with dissection under the inferior mesenteric artery, working laterally to identity the left ureter and lateral abdominal wall. Care should be taken to identify the sympathetic trunks to avoid damage and cause sexual or urinary problems. Sharp dissection in the presacral avascular space mobilizes the rectum. Laterally, one may encounter the middle hemorrhoidal vessels, which may be either clamped and divided or simply sealed with cautery. Anterior dissection should be last, with separation of the rectum from the prostate or vagina. Transection of the anococcygeal ligaments completes the mobilization of the rectum. Ligate the proximal vessels of the superior hemorrhoidals/IMA.

The following procedure depends on whether LAR or APR is chosen. If APR is chosen, transect the proximal sigmoid with a longitudinal stapler or with clamp in place. Construction of a permanent stoma can be made in a previously-marked left lower quadrant and the descending colon delivered. The perineal portion is done with the patient in a lithotomy or jack-knife position. Synchronous combined APR with a separate abdominal and perineal operator facilitates this surgery. Place a purse string around the anus, then carry the dissection out from posterior to lateral and finally anterior dissection. Expose the levator ani muscles. Transect the muscles and circumscribe the rectum to deliver the specimen. During the dissection always confirm that you are protecting the urethra and vagina. Gauze may be used for temporary tamponade. Deliver the specimen through the perineum. Close the pelvic floor by approximating the levator muscles, subcutaneous tissues and finally the skin. Occasionally a dexon or vicryl mesh at the pelvic inlet will keep bowel from filling the pelvis. Leave a suction drain in place. Re-glove and mature the ostomy that was previously delivered outside the abdomen.

Low anterior resection (LAR) has been increasingly used for low rectal cancers since the 1950's to avoid the permanent stoma associated with abdominoperoneal resection. Outomes following a LAR are not significantly different from those following APR (24). Data from the National Surgical Adjuvant Breast and Bowel Project (NSABP) trial demonstrated that there are no significant differences in survival or local recurrence when comparing distal rectal margins of <2 cm, 2 to 2.9 cm, and >3 cm. As a result, a 2 cm distal margin has become acceptable, providing the tumor is not poorly differentiated and circumferential margins are adequate. A 5 cm proximal margin is still preferred. A positive radial margin is an independent predictor of both local recurrence and decreased survival (25). Newer stapling devices have allowed a colorectal or colo-anal anastomosis with good results. The sphincter is preserved and the need for a stoma is avoided. The lower the anastomosis is constructed in the anal canal, the higher the anastomotic leakage rate (26). Moreover, stool frequency may be increased. Different pouches have been constructed to improve quality of life and are discussed below.

For LAR the patient is positoned in a modified lithotomy position and the procedure performed, as described earlier, up to ligation of the middle hemorrhoidal arteries. Dissect up to the levator ani and dissect at least 2cm below the tumor. Extended LAR with mobilization of the left colon might be necessary to prevent anastomotic tension. The inferior mesenteric artery might have to be scarified. Divide the colon with a longitudinal stapler or with clamps in place. Deliver the specimen. Anastomosis can be either done by hand or by staplers, with or without a pouch. If hand-sewn, single layer with nonabsorbable suture has been shown to have comparable leak rate while decreasing operative time and money compared two layer (38). Drains may be placed if deemed necessary. Close the abdominal wall and skin. Often, a proximal diverting ileostomy is constructed in those patients with tenuous or very low anastomosis, or in those patients receiving pre- and/or post-operative chemoradiation therapy.

A colonic J-pouch is one of the most common pouches used to restore bowel continuity in coloanal anastomoses. The pouch is created by folding distal bowel back on itself for about 6cm, dividing the resulting septum and creating a common apex channel to the anus. It has superior functional results for the first two years over a straight anastomosis (27). With such a pouch, the number of stools per day is less and with it the quality of life increases. If for some reason a J-pouch is not technically possible, a transverse coloplasty-anal anastomosis may be an option. This is created by making a 8cm longitudinal colotomy approximately 5 cm above the anastomosis and then closing it transversely (analogous to a closure for pyloric stenosis).

As with many other procedures, laparoscopic approaches have been used. Studies evaluating laparoscopic-assisted procedures show that it is both feasible and safe (28). Morbidity, such as pain, postoperative ileus and length of stay, might actually be reduced while oncologic outcome is not compromised. Initial reports for rectal cancer demonstrated slightly higher rates of post-operative sexual dysfunction.

Lastly sentinel lymph node sampling can also be used in rectal cancer. The sentinel node is the first node that receives lymph and is most likely to contain metastatic cells. It is accurately identified in 99% of cases, (29) though the clinical utility has been questioned and the procedure has not found widespread adoption.

7. Medical Therapy

Despite significant advances in surgical therapy for rectal cancer, recurrence and metastases still occur in a significant number of patients. Radiotherapy has resulted in better local control while chemotherapy has been used to eradicate micro-metastases. Many large studies have shown that the addition of chemradiation increases eradication of tumor locally compared to radiotherapy alone. No significant improvement was seen in distant metastases or survival (30). In general, T3 and T4 (Stage II) tumors along with all stage III and IV disease are definite indications for chemo-radiation which may be given pre- or post-operatively.

Pre-operative (neoadjuvant) treatment is often used for patients with locally advanced or fixed rectal cancers. It can reduce tumor size and increase respectability (31). Post-operative (adjuvant) radiation is also used when either resection was grossly or microscopic incomplete, with the former having worse results (32). Radiotherapy without surgery is not indicated unless only palliation is expected.

Radiation without chemotherapy is not widely practiced. The evidence supports the addition of combined chemoradiation with better sphincter preservation, better lower control and similar long-term survival (33). Newer approaches include 5-FU in combination with oxaliplatin, irinotecan and capecitabine with oxaliplatin. Newer chemotherapeutics such as the epidermal growth factor and vascular endothelial growth factor inhibitors, though commonly used as second-line treatments, are still undergoing investigation to determine their most appropriate role.

Intraoperative electron beam radiation has been used in conjunction with pre-operative radiation and/or chemotherapy for tumors that have gross margins after resection or significant fixation (34). High-risk areas are determined to establish the field of radiation by the surgeon and in cooperation with the oncologist.

Finally, recurrent rectal cancer remains a significant challenge. The choice of therapy can include all those discussed above and depend in part on prior therapy modalities used and the extent of recurrence: local or metastatic. Thus extensive evaluation, often including CT and PET, to determine the extent of disease is imperative. Palliation is offered if the tumor is found to be unresectable and/or significant metastases have occurred. Therapies include stenting, bowel bypass surgery or palliative tumor resection. As with colon cancer, isolated liver and lung metastasis should be considered for resection.

Although medical therapy is widely available in developed countries, its availability is limited in under-developed countries. Cancer centers where radio-and chemotherapy are available are being established, but are scarce and still in the developing stage. This is one area where improvement can have a significant impact on this disease.

8. Screening

Screening for rectal cancer is the same as for colon cancer. The rationale includes detection of both premalignant polyps, to prevent the onset of cancer, as well as of early disease in asymptomatic patients to increase the survival rate. In the West, screening is recommended for average-risk people older than 50 years as well as in people 40 years old and older who have a family history of CRC. Guidelines include fecal occult blood testing every year combined with flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5-10 years, and colonoscopy every 5-10 years. These can be varied based on the results of prior examinations, as well as changing risk stratification based on personal or family history. Recently virtual colonoscopy every 5 years has been added to the list (35).

9. Prognosis and Complications

Five-year survival rates for rectal cancer are generally lower than those for colon cancer. In general the 5-year survival is 80-90% for Stage I, 55% for stage II, 40% for stage III and <10% for stage IV. Recurrence is seen in up to 30% of patients and is dependent on surgical technique, grade and stage of disease, location of tumor and ability to obtain negative margins.

Quality of life after surgery is very important. Main issues include fecal incontinence, genitourinary incontinence, sexual dysfunction and permanent stomal care. Although TME has made a great impact on the surgical cure of rectal cancer it has also added to the potential cost of these quality of life issues. A good indicator of continence is the level of anastomosis. A lower anastomosis is associated with an increased incidence of incontinence (36) . One area of interest is sphincter replacement surgery either by electrically stimulated skeletal muscle or an artificial sphincter. These are not widely practiced and are discouraged at the time of the operation.

Other surgical complications include wound infection, wound dehiscence, hernia, fistulae, hematomas, bowel obstruction and adjacent organ injury. Adverse effects from adjuvant therapy are common, both from radiation and chemotherapy. These include diarrhea, mucositis, neutropenia, hair loss, skin hypersensitivity, irradiated organs, adhesions, increased anastomotic leak rates and others.

10. Conclusion

Rectal cancer is a major health concern worldwide. As with most diseases, prevention including primary, secondary and tertiary prevention, is preferable. There have been major surgical advances made and chemoradiation is changing how we look at rectal cancer. Rectal cancer presents a formidable challenge to the patient and surgeon alike. High local recurrence rates, difficult deep pelvic surgery and avoidance of a permanent colostomy dominate treatment decisions. Good technique and focused training can result in better outcomes. Adjuvant and neo-adjuvant therapies have been shown to diminish local recurrence, improve survival and alter surgical approaches for better spincter preservation. ERUS and MRI are important investigations in patients with early disease. An important challenge will be implementing these advances in the treatment of rectal cancer, especially in undeveloped countries. Radio- and chemotherapy is still not widely available in these countries and the number of experienced oncologic or hepatobiliary surgeons for liver resections is limited. One can, however, not over-emphasize the importance of a multi-disciplinary approach. This will improve the outcome of rectal cancer. Fields of general surgery, radiation oncology, medical oncology and gastrointestinal medicine all should be involved.

Lionel R. Brounts, MD*, Robert Zulu, MD⁺, Scott R. Steele, MD*

*Department of Surgery, Madigan Army Medical Center, Tacoma, Washington. ⁺Department of Surgery, School of Medicine, Lusaka, Zambia

Corresponding author:

Scott R. Steele, MD
Department of Surgery
Madigan Army Medical Center
Fort Lewis, WA 98431
Phone: (253) 968-2200
Fax: (253) 968-0232; 968-5900
Email: harkersteele@mac.com

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