ADENOCARCINOMA RECTUM

✓ The evaluation and treatment of rectal cancer differs from that of colon cancer
considering the following anatomic factors: (1) Rectum is deeply located in the
pelvis. The anatomical constraints of the bony pelvis and proximity to sphincters,
urogenital structures, and autonomic nerves poses technical difficulties in
achieving curative resections. (2) Rectum exhibits dual blood supply and
lymphatic drainage. Understanding these vascular and lymphatic intricacies is
crucial for addressing metastatic pathways and planning effective treatment
strategies (3) Rectum is accessible transanally, allowing for certain diagnostic and
therapeutic procedures.
✓ Historically, rectal cancer surgeries were associated with a significant locoregional
recurrence rate, reaching up to 40% until the late 1980. The transformative shift in
the management of rectal cancer occurred with the introduction of Total
Mesorectal Excision (TME) by William Heald in 1982. Locoregional recurrence
rates plummeted from the previously alarming 40% to a substantially lower 9%
with the implementation of TME. With the incorporation of neoadjuvant
chemoradiotherapy alongside TME, the local recurrence rates for rectal cancers
have been further diminished, reaching an impressively low 5%.
✓ The type of therapy offered to a patient with rectal cancer depends not only on
the stage of the tumour but also on its location within the rectum and its relation
to the anal sphincters. A comprehensive understanding of anatomical landmarks
are critical in determining resectability and sphincter preservation in patients
with rectal cancer.
A. Surgical anatomy of rectum
✓ The rectum begins where the tinea coli of the sigmoid colon joins to form a
continuous outer longitudinal muscle layer at the level of the sacral promontory.
The rectum follows the curve of the sacrum and coccyx and ends at the anorectal
ring, an anatomic landmark palpable on physical examination and visible
radiographically as the upper border of the anal sphincter and puborectalis
muscles. The anorectal ring/ junction is at 4 cm from the anal verge. The rectum
lacks a true mesentery, haustrations, tinea coli and appendices epiploicae.
✓ Although the total length of the rectum can vary by body habitus and sex, by
definition, the upper limit of the rectum (rectosigmoid junction) is at 15 cm from
the anal verge on rigid proctoscopic examination.
✓ In practice, the location of a rectal cancer is identified by its distance from the
anal verge. The anal canal is 0 to 4 cm from the anal verge to anorectal junction.
Low (distal) rectal cancers are located 4 to 8 cm from the anal verge, middle rectal
cancers 8 to 12 cm, and upper (proximal) rectal cancers 12 to 15 cm. However,
surgical decision making for sphincter preservation is dependent mostly upon the
distance from the lower border of the tumour to the top of the anorectal ring (i.e.,
top of the sphincter complex) rather than the anal verge.
✓ Human rectum is not straight but has three lateral curves: the upper and lower
curves are convex to the right, and the middle is convex to the left. Because of its
curves, the rectum can gain 5 cm in length when it is straightened (as in
performing a low anterior resection); hence, a lesion that initially appears at 7 cm
from the anal verge is often found 12 cm from that site after complete
mobilization.

✓ Peritoneal reflections:
• The upper third of the rectum (12-15 cm) is covered by peritoneum anteriorly
and laterally, the middle third is covered (8-12 cm) by peritoneum only
anteriorly and then reflected over the bladder in males and the uterus in
females (anterior peritoneal reflection) and the lower third (4-8 cm) is totally
extraperitoneal.
• In the male patient, the anterior rectum is fixed to Denonvillier’s’ fascia that
separates the rectum from the posterior prostate and seminal vesicles. In the
female patient, the peritoneal cavity descends to the pouch of Douglas, with its
 most dependent point being adjacent to the cervix anteriorly and mid-rectum
posteriorly.
• The anterior peritoneal reflection is the lowest dependent part of the
peritoneal cavity. It is clinically important as a common location of fluid and
pus accumulation and may serve as a site of peritoneal metastases from visceral
tumours. These “drop” metastases can form a mass in the cul-de-sac (Blumer
shelf) that can be recognized on digital rectal examination.

✓ Fascial attachments:
• The walls and floor of the pelvis are covered by the endopelvic parietal fascia.
At the pelvic floor, parietal fascia gets reflected and extends on to the rectum
and forms the endopelvic visceral fascia called as the fascia propria / investing
fascia of the rectum and encloses the rectum and its mesorectal fat, lymphatics,
and vascular supply as a single unit.
• Posteriorly, the endopelvic parietal fascia is strong, forming the presacral
fascia, that covers the median sacral vessels, sacrum, and coccyx. The presacral
fascia that extends from the periosteum of the fourth sacral segment to the
posterior wall of the rectum is known as rectosacral fascia or Waldeyer’s
fascia. This fascia should be sharply divided with scissors or electrocautery for
full mobilization of the rectum.
• Anteriorly, the endopelvic parietal fascia forms thin Denonvillier’s fascia that
separate the fascia propria of rectum from seminal vesicles and prostate in
males and vagina in females.
• Laterally, lamina propria of rectum fuse to form the “lateral stalks” or ligaments.
It is important to remember that in about 30% of cases, a branch of the middle
rectal artery may traverse these ligaments and may cause bleeding when
cutting through them.

✓ Mesorectum:
• Mesorectum is a term employed by surgeons to describe the perirectal tissue
composed of fat, peri rectal lymph nodes, lymphatics and branches of superior
rectal artery & vein and enveloped by the endopelvic visceral fascia (fascia
propria/ mesorectal fascia).
• The mesorectum begins at the rectosigmoid junction, extends along the length
of the rectum, tapers down and ends at levator ani. Mesorectum is well
developed posteriorly and thinner anteriorly and laterally.
 • Total mesorectal excision (TME) implies the removal of the entire mesorectum
within its enveloping fascia as an intact unit.
• The failure to completely excise this envelope intact has been correlated with a
30% risk of local recurrence in rectal cancer cases. Pioneering work by William
Heald has demonstrated that TME significantly reduces the recurrence rate
to 5%.
✓ Blood Supply:
• The blood supply to the rectum is derived from the superior, middle, and
inferior rectal arteries. All three rectal arteries are connected with a strong
anastomotic network, which helps avoid rectal ischemia after dividing the
superior rectal arteries during anterior resections.
• The superior rectal artery originates from the inferior mesenteric artery and
descends in the mesorectum to supply the upper and middle rectum.
• The middle rectal arteries are paired vessels and are branches of the internal
iliac arteries and reach the lower rectum through the lateral stalks. They are
not considered a major blood supply to the rectum and are found inconstantly.
They can be inadvertently injured when dividing the lateral ligaments.
 • The inferior rectal arteries are branches of the internal pudendal arteries and
generally supply the anus distal to the dentate line.

✓ Venous drainage:
• The superior rectal vein drains the upper two thirds of the rectum, draining
into the IMV and portal system.
• The lower rectum and anus drain into the middle and inferior rectal veins,
which drain into the internal iliac and systemic circulation. This drainage
pattern explains the higher rate of lung metastases observed with low rectal
cancers as compared to mid and upper rectal cancers, which are much more
likely to metastasize to the liver.

✓ Lymphatic drainage:
• The lymph from the upper two thirds of the rectum drains upward toward the
inferior mesenteric and paraaortic nodes. The lower part of the rectum drains
in two directions, cephalad toward the inferior mesenteric nodes and laterally
and inferiorly toward the common iliac, internal iliac and obturator nodes.
Below the dentate line, lymph drains toward the inguinal lymph nodes.

A. Blood supply and B. Venous drainage of the rectum and anal canal
 Lymphatic drainage of
the rectum and anus

A. Nodes at the origin of the

inferior mesenteric artery.
B. Nodes at the origin of
sigmoid branches.
C. Sacral nodes.
D. Internal iliac nodes.
E. Inguinal nodes

✓ Innervation:
• The sympathetic innervation of the rectum is derived from sympathetic nerves
exiting at the level of L1–3, forming the superior hypogastric plexus. At the
level of the sacral promontory, they divide into left and right hypogastric
nerves, traveling on both sides of the pelvis.
• The parasympathetic nerves, or Nervi erigentes, arise from S2 to S4 and join
the hypogastric nerves anterior and lateral to the rectum to form the pelvic
plexus and ultimately the periprostatic plexus.
• The inferior hypogastric nerve plexus arises from interlacing sympathetic and
parasympathetic nerve fibres and present on the lateral pelvic sidewall. Fibers
from this plexus innervate the rectum as well as the bladder, ureter, prostate,
seminal vesicles, membranous urethra, and corpora cavernosa.
• Therefore, injury to these autonomic nerves can lead to impotence, bladder
dysfunction, and loss of normal defecatory mechanisms.

B. Staging:
✓ The purpose of staging any cancer is to describe the anatomic extent of the
tumour. Staging aids in planning treatment and determining the prognosis.
 ✓ Currently, the most widely accepted staging system for rectal cancer is the TNM
classification system. The TNM staging system is based on depth of tumour
invasion as well as presence of lymph node or distant metastases.

SIMPLIFIED TNM STAGING OF RECTAL CANCER

T1 Tumour invading submucosa
T2 Tumour invading the muscularis propria
T3 Tumour penetrating the muscularis propria into perirectal fat
(mesorectum)
T4a Tumour penetrating visceral peritoneum (fascia propria)
T4b Tumour directly invading or adhering to other organs or structures

N0 No lymph node metastasis

N1 1–3 lymph node metastases
N2 ≥ 4 lymph node metastases

M0 No distant metastasis
M1 There are distant metastases
M1a: Metastases limited to 1 organ
M1b: Metastases to more than 1 organ
M1c: Peritoneal metastases
T- score N-score M-score
Stage-I T1, T2 N0 M0
Stage-II T3, T4 N0 M0
Stage-III Any T N1-2 M0
Stage-IV Any T Any N M1

C. Preoperative evaluation of patients with rectal cancer

In Western countries with established population-based screening programs, rectal
cancer is diagnosed in an asymptomatic patient as a result of a positive screening test
but in majority of instances, rectal cancer is diagnosed on workup of a symptomatic
patient. Symptoms associated with rectal cancer include bleeding per rectum, tenesmus
& early morning diarrhoea.

1. Digital rectal examination (DRE)

• DRE can detect tumours within palpable range of the examining finger, typically
those located within 7-8 cm of the anal verge. DRE can give information on the
tumour size, anterior or posterior location, mobility, ulceration, local invasion,
 and fixation, lymph node status, relationship of tumour to the sphincter complex
and distance of the tumour’s lower margin from the anorectal junction as well as
from the anal verge.
• DRE also provides an opportunity to evaluate the integrity of the anal sphincter
complex. Patients with good anal sphincter tone are suitable candidates for
treatment by a sphincter-sparing surgery.
• For anteriorly located rectal cancer in women a vaginal examination is done to
determine invasion of the posterior vaginal wall (rectovaginal septum).
2. Rigid proctosigmoidoscopy
• For lesions that are not palpable on DRE, the surgeon should also perform a rigid
proctosigmoidoscopy to localise the lesion and determine the distance between
distal extent of the tumour and anal verge. Flexible sigmoidoscopy is not used
routinely because the flexibility of the instrument can give false measurements.
3. Colonoscopy
• All patients with suspected rectal cancer should undergo a full colonoscopy.
Colonoscopy enables the direct visualisation of the rectal lesion and ensures a
histological diagnosis by obtaining sufficient tissue samples from the lesion for
subsequent histopathological analysis.
• A full colonoscopy allows comprehensive visualization of the entire
colorectum. This is important because synchronous proximal cancers are
detected in 3% of patients with rectal cancer. If a synchronous carcinoma is
present, the operative strategy is likely to change.
• If a full colonoscopy is not possible, for example when there is a stenosing
cancer, a CT colonography or double contrast barium enema can be performed.
4. Biopsy & Histopathological analysis
• Biopsy and histopathological analysis remain the mainstay of diagnosis of rectal
cancer. Biopsy can be safely obtained during colonoscopy and the tissue samples
are subsequently sent for histopathological examination.
• Histological type: Carcinoma of the rectum is primarily an adenocarcinoma,
derived from malignant transformation of the columnar rectal epithelium. Two
rare variants of adenocarcinomas are mucinous adenocarcinoma and signet ring
type in which the cancer cells produce excess mucin. Patients with signet ring cell
carcinomas had the worst prognosis.
 • Biopsy plays a crucial role in not only confirming the adenocarcinoma type but
also in excluding other type of rectal cancers like squamous cell carcinoma,
melanoma, sarcoma, or lymphoma, each requiring distinct treatment strategies.
• Tumour grade: Tumour grade is indicative of the aggressiveness of the cancer.
Well-differentiated tumours, where cancer cells maintain a normal shape and
arrangement, are associated with less aggressive behaviour. Conversely,
undifferentiated tumours with a higher proportion of cells deviating from the
normal cell type signify a more aggressive behaviour.
• Other poor prognostic features on HPE include vascular and perineural invasion,
the presence of an infiltrating (rather than pushing) margin and tumour budding.
5. Transrectal Ultrasound (TRUS) / Endorectal ultrasound (ERUS)
• Transrectal Ultrasound (TRUS) effectively delineates the various layers within the
rectal wall, providing valuable insights into the depth of cancer invasion.
• TRUS excels as the imaging modality of choice for early rectal cancers. When
distinguishing between T1 & T2 lesions, TRUS stands out as the preferred
diagnostic tool.
• Nevertheless, the majority (80%) of rectal cancer cases encountered in daily
practice are often locally advanced. In such scenarios, TRUS is not as sensitive as
MRI in assessing nodal status, mesorectal fascia infiltration and involvement of
adjacent structures.
• Additionally, TRUS is operator-dependent, and cannot be performed in cases of
obstructed rectal cancers.
6. Rectal cancer protocol magnetic resonance imaging (MRI)
• MRI is the best modality for assessing the depth of invasion, the extent of
mesorectal infiltration, the involvement of mesorectal lymph nodes, the potential
involvement of the mesorectal fascia, the circumferential resection margin status,
and the status of adjacent structures-whether they remain free or are infiltrated by
the tumour, which is not possible with TRUS. MRI is the investigation of choice
for local staging in the majority of rectal cancers whereas ERUS is modality of
choice for early-stage rectal cancer.
• This detailed information provided by pelvic MRI is crucial in making informed
decisions about the necessity for preoperative chemoradiation therapy.
• Currently, clinically T3, T4 and node positive rectal cancers and those with
cancers in close proximity of the sphincter in whom sphincter sparing is desired
are recommended to undergo preoperative neoadjuvant chemoradiation.
7. CT scan of thorax, abdomen, and pelvis (TAP)
• All patients with a diagnosis of rectal cancer should undergo staging CT of the
thorax, abdomen, and pelvis (TAP) to look for concurrent metastatic disease in
the liver and lungs.
8. CEA levels
• A carcinoembryonic antigen (CEA) level should be obtained for every patient
before surgery. It must be noted that the purpose of the CEA is not for screening
or diagnosis. Instead, CEA is used as a prognostic and post-treatment surveillance
tool. Therefore, a baseline measurement of CEA should be obtained in all patients
prior to any treatment.
• Patients with preoperative serum CEA ≥ 5 ng/mL have worse prognosis, stage for
stage, than patients with serum CEA < 5 ng/mL.

• Normalization of CEA in patients with an elevated serum CEA who are

undergoing neoadjuvant therapy is a strong predictor of complete pathologic
response.
• Elevated CEA levels that do not normalize after curative resection should raise the
suspicion of residual disease and should prompt further evaluation.
9. PET-CT has no role in the initial evaluation of rectal cancers. However, it becomes
valuable during follow-up of patients who have undergone treatment for rectal
cancer. Patients with rising CEA levels after curative resection should undergo PET-
CT scan to rule out local and/or distant recurrence.

D. Principles of Treatment
Surgical resection is the cornerstone of curative therapy, but surgery alone provides a
high cure rate only for patients with early stage (stage I) disease. But majority of rectal
cancers are locally advanced at their presentation, hence, a multimodality approach
consisting of neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal
excision (TME) surgery, and adjuvant chemotherapy has become the standard of care for
these locally advanced rectal cancers (LARC).

1. Multidisciplinary Tumour Board

✓ After establishing the diagnosis and completing the staging workup, all patients
with rectal cancer should be discussed at a multidisciplinary tumour board
conference. A MDT should consist of a panel of surgeons, radiologists,
 pathologists, medical oncologists, and radiation oncologists that are specialized in
the care of patients with rectal cancer.
✓ Management decisions to proceed with neoadjuvant therapy, upfront surgery, or
other strategies are decided on using a consensus multidisciplinary team approach.
✓ Specifically for rectal cancer, the implementation of multidisciplinary tumour
boards was associated with lower incidences of permanent stoma and local
recurrence, improved delivery of evidence-based care, and better overall survival.

2. Neoadjuvant therapy

✓ Neoadjuvant chemoradiotherapy is currently recommended for all stage II and III

patients with tumours located in the distal two-third of the rectum. The use of
neoadjuvant therapy has led to a significant reduction in local recurrence rates for
patients with resectable adenocarcinoma of the rectum.
✓ At present, the standard of care for neoadjuvant therapy includes:
• Long-course chemoradiation: 45 Gy delivered in 25 fractions over 5 weeks
with a boost to the tumour bed of 5.4 Gy in 3 fractions for a total of 50.4 Gy
in 28 fractions with a concurrent 5-day continuous infusion of 5-FU or oral
capecitabine (radio-sensitizing agent) during the first and fifth weeks
followed by transabdominal resection surgery after a window of 6 to 8 weeks.
• Short-course preoperative radiotherapy: 25Gy delivered in 5 fractions over
1 week, followed by immediate surgery some 7–10 days after completion of
therapy.
✓ One potential benefit of long course chemoradiation is the potential for
significant downsizing or downstaging the cancer and increase the chances of a
complete resection with clear oncological margins. Therefore, long course therapy
is recommended for patients with clinical T4 or large bulky tumours and tumours
in close proximity to sphincter.
✓ Alternatively, preoperative ‘short course’ (5 days) radiotherapy can be used if the
resection margins are not threatened but the cancer is still at high risk for local
recurrence (e.g., high grade tumour) and to ‘sterilise’ the operative field in cancers
with suspected lymphovascular involvement.

3. Total neoadjuvant therapy (TNT):

✓ TNT includes four months of upfront chemotherapy typically with FOLFOX

regimen (5-fluorouracil plus leucovorin and oxaliplatin), followed by concurrent
 chemoradiation, followed by surgery. In this therapy both systemic chemotherapy
and neoadjuvant CRT is delivered prior to surgery. TNT may be considered for
patients with locally advanced or bulky primary tumours (T4), or for patients
with extensive nodal disease (N2). TNT may cause significant downsizing of a
bulky rectal cancer and make negative margin resection (R0 resection) and
sphincter preservation possible. Accumulating evidence shows that TNT improve
survival and reduce risk of distant metastases via systematic chemotherapy to
prevent the onset of micrometastases.

4. Watch and Wait Policy:

✓ About 20% of rectal cancers treated by long-course neoadjuvant
chemoradiotherapy show a complete clinical response, with no evidence of
residual cancer upon clinical examination, biopsy, or radiological imaging. An
emerging approach involves adopting the 'watch and wait' strategy, as advocated
by Habr Gama, for these patients, in the hope that they may have been cured of
the disease without subjecting them to the associated morbidity of resectional
surgery. Although there is a 30% recurrence rate in patients under the 'watch and
wait' strategy, the majority of cases can be salvaged through surgical resection.

5. Organ preserving surgery / Local excision of rectal cancers:

✓ Local excision is best applied to rectal cancers staged as T1 by EUS within 10 cm
of the anal verge, less than 3 cm in diameter involving less than one-third of the
circumference of the rectal wall, highly mobile, not fixed, favourable histology on
biopsy (low grade tumours), and without radiological evidence of nodal
involvement (N0 disease).
✓ Local excision may also be offered to those who have more advanced diseases
(≥cT2) but who are medically unfit for radical transabdominal resection surgery
after sufficient counselling.
✓ Local excision usually involves full thickness excision of the cancer using TEMS
(Transanal endoscopic microsurgery).

6. Transabdominal radical resection surgeries:

✓ Majority of patients have more deeply invasive tumours that do not meet the
criteria for local excision. Such patients will require a transabdominal excision,
and the specific techniques used depend on the stage and location of the tumour
within the rectum.
✓ Tumours in the upper and middle rectum can usually be managed with a
sphincter-sparing procedure, such as Low anterior resection [LAR], provided that
a curative resection can be achieved, and adequate anorectal function preserved.
✓ Tumours in the lower rectum (i.e., tumours within 5 cm of the anal verge may
require an Abdominoperineal resection [APR] if a curative resection cannot be
achieved with sphincter-sparing procedures.
✓ Alternatives to APR for patients with lower rectal tumour have evolved and
include the following:
o For selected patients with small lower rectal tumours, local excision
techniques may offer local control and survival rates that are comparable to
APR while preserving sphincter function.
o For patients with larger or more invasive lower rectal tumours, preoperative
(neoadjuvant) radiation therapy (RT) and chemoradiotherapy (CRT) have
been utilized to promote tumour regression in an attempt to convert a
planned APR into a sphincter-sparing surgical procedure, such as LAR.
✓ Locally advanced tumours involving adjacent pelvic organs or bony structures
may require en bloc multivisceral resection (e.g., pelvic exenteration) to achieve
negative resection margins (Curative resection).
✓ Transabdominal rectal cancer surgery can be performed via open, laparoscopic, or
robotic approaches. The best surgical approach needs to be determined
individually by tumour and patient characteristics, as well as surgeon experience;
one approach has not been shown to be superior to the others
✓ Preoperative preparation
o Recent guidelines recommend preoperative bowel preparation for all rectal
cancer patients who are undergoing transabdominal radical resection
surgeries. Mechanical bowel preparation (MBP) is usually done with an
osmotic agent such as PEG with an electrolyte solution. The PEG–
electrolyte solution is prepared in 2 litres (L) of water. The patient drinks
2 L of PEG–electrolyte solution and 1 L of clear fluid on the evening before
the day of surgery. PEG-ELS thoroughly cleanse the colon and rectum and
reduce intraoperative contamination and the risk of surgical site infection.
o A preoperative course of oral antibiotics (2 g of neomycin orally at 7 pm
and 2 g of metronidazole orally at 11 pm the day before surgery) is
administered. In addition, intravenous broad spectrum prophylactic
antibiotics are given at induction of anaesthesia before surgical incision.
 There is evidence to suggest that prophylactic systemic antibiotics may
reduce the risk of septic complications, including anastomotic leak.

✓ Principles of Transabdominal radical resection surgeries: The primary goal

of radical rectal cancer resection surgery is to achieve a histologically negative
margin resection of the primary tumour (R0 resection), performing a total
mesorectal excision (TME) that includes resection of local lymph nodes and high
ligation of the arterial pedicle that includes resection of regional lymph nodes.
Additional goals include restoration of intestinal continuity and preservation of
anorectal sphincter, sexual, and urinary function when possible. All
transabdominal surgical resection of the rectum must achieve all of the following:

a) Total mesorectal excision: Total mesorectal excision (TME) described and

popularised by William Heald has led to a dramatic decrease in local
recurrence of the disease. TME involves sharp dissection under direct vision in
the avascular, areolar plane between the fascia propria of the rectum, which
encompasses the mesorectum, and the parietal fascia overlying the pelvic wall.

o TME ensures the dissection proceed in the ‘holy plane of Heald’ and
preserves the autonomic nerves (ANP) and reduces the risk of presacral
bleeding and avoids violation of the mesorectal envelope. This results in a
characteristic bilobed, smooth, glistening surface of the excised mesorectum.
Preservation of the pelvic autonomic nerves reduces the risk of lower rate of
postoperative sexual and bladder dysfunction.
 o Because rectal cancer spread appears to be limited to the mesorectal
envelope, its total removal should encompass virtually every tumour
satellite, thus improving the likelihood of local control.

o Moreover, Heald described a “zone of downward spread” within the

mesorectum and recommended the complete excision of the mesorectum
in all rectal cancers to minimize local recurrence. However, research
indicates that even in T3/T4 tumours, tumour implants within the
mesorectum are typically confined to a maximum distance of 4 cm from
distal edge of the tumour. Therefore, the latest recommendation is a
Tumour specific MSE: For cancers located in the upper rectum, the
mesorectum transected at right angle to the rectal wall at a distance of 5 cm
beyond the distal edge of the primary tumour. Complete removal of the
mesorectum down to the pelvic floor (TME) is necessary for cancers in the
middle and lower third of the rectum.

b) Resection margins: In rectal cancer, local spread is principally

circumferential/ radial rather than in a longitudinal direction. After the
muscular coat has been penetrated, the growth spreads into the surrounding
mesorectum and spread is initially limited by the mesorectal fascia.
Longitudinal intramural spread is generally limited to 2 cm which explains the
general rule of obtaining a 5-cm proximal and distal margin in all colorectal
surgeries.

o Proximal margin: In carcinoma rectum, obtaining 5 cm proximal negative

margin is technically easy and entire sigmoid colon can be resected but
obtaining circumferential resection margin (CRM) and distal resection
margin (DRM) is critical.
o Radial margin: Radial margin clearance can be achieved with total
mesorectal excision (TME). The tumour distance from the intact
mesorectal fascia has been defined as the critical circumferential resection
margin (CRM) and a CRM of >1 mm is acceptable. Positive CRM typically
is due to an incomplete total mesorectal excision (TME), from violation of
the mesorectal envelope and disruption of the mesorectum.
o Distal margin: In the pre-TME era a DRM of at least 5 cm was mandatory.
For that reason, almost all patients with rectal cancer near the sphincter
 complex had to undergo abdominal perineal resection. With introduction
of the TME surgery and preoperative chemoradiotherapy (CRT) the 5 cm-
rule has been abandoned and a DRM of 2 cm was found to be oncological
sufficient. For cancers located at or below the distal mesorectal margin, a 1
cm negative distal margin is acceptable. Margins of resection must be
histologically negative on the final pathology report. Intersphincteric
resection may help extend the distal margin by removing the internal
sphincter muscle in suitable candidates.

c) Lymphovascular pedicle ligation: In most patients with rectal cancer, a

lymph node dissection up to the level of the origin of the superior rectal vessels
from IMA should be performed. Division and ligation of the inferior
mesenteric artery (IMA) below the origin of the left colic artery (low tie
technique) is typically appropriate for rectal cancer resection.s
 o "High" ligation of the inferior mesenteric artery at its origin at the aorta, is
necessary in the presence of clinically positive nodes at the level of IMA.
High ligation also allows for maximal mobilization of the proximal bowel
to facilitate a tension-free low pelvic or coloanal anastomosis (CAA)

o A benchmark of 12 lymph nodes has been adopted as a quality metric for

an adequate colorectal cancer surgery although the number of lymph nodes
recovered may be lower after neoadjuvant chemoradiation therapy.
o Lateral (or extended) pelvic lymph node dissection removes the nodal
compartment along the common iliac, internal iliac, and obturator arteries.
Persistent enlarged lateral compartment lymph nodes after neoadjuvant
chemotherapy is an indication for lateral pelvic lymph node dissection.

d) Anastomosis:
o Provided that a negative distal margin can be achieved, an important goal of
rectal cancer surgery is to spare the anal sphincter, which preserves continence
and permits reestablishment of bowel continuity.
o **Anterior resection: ** An Anterior resection is a sphincter sparing radical
resection surgery and includes partial or total resection of the rectum followed
by a colorectal or coloanal anastomosis to reestablish intestinal continuity.
Patients with a rectal cancer that meets all of the criteria below should
undergo a sphincter-sparing resection:
o Invasive rectal cancer cT2-4
o A negative distal margin can be achieved
o Adequate presurgical anorectal sphincter function

If the anastomosis is above peritoneal reflection, it is high anterior resection

If the anastomosis is below peritoneal reflection, it is low anterior resection

If anastomosis is at the pelvic floor, it is ultra-low anterior resection

o Rectosigmoid cancers and those in the upper 1/3rd of the rectum are removed
by ‘high anterior resection’, in which the rectum and mesorectum are taken to a
margin of at least 3 cm distal to the tumour and a colorectal anastomosis
(CRA) is performed. CRA is usually achieved by means of a stapled
anastomosis. The simplest way of achieving this is by using a ‘double stapling’
technique, whereby a circular stapling device is passed transanally to
 anastomose the stapled ends of the proximal colon and rectal stump. Patients
of upper 1/3rd rectal cancers undergoing anterior resection followed by
colorectal anastomosis typically have sufficient rectal reserve.
o For tumours in the middle 1/3rd and lower 1/3rd of the rectum, complete
removal of the rectum (proctectomy) and total excision of mesorectum is
required, i.e. TME (Heald) and gastrointestinal continuity is reestablished by a
coloanal anastomosis (CAA). Bowel function after CAA following low and
ultra-low anterior resection is altered due to loss of the rectal ‘reservoir’ and
low-lying anastomoses may be associated with urgency, increased frequency
and clustering of bowel movements for at least one year postoperatively
(Anterior resection syndrome).
o Several techniques of coloanal anastomosis have been developed to improve
postsurgical bowel function, including colonic J-pouch reservoir, side-to-end
(Baker) anastomosis, and transverse coloplasty, to augment the residual
reservoir after proctectomy and potentially improve postoperative function.
e) A temporary diverting stoma should be constructed to protect an
anastomosis in all patents who underwent low & ultra-low anterior resections
with anastomosis below the peritoneal reflection or at the level of pelvic floor
(< 5 cm from anal verge) and all patients who underwent preoperative pelvic
radiation.
o For temporary diversion, loop ileostomy is generally preferred over loop
colostomy for ease of reversal; however, loop ileostomy is associated with a
higher incidence of high stoma output and dehydration.
o From a practical standpoint, the complications related to a temporary
diverting stoma are easily manageable, whereas an undiverted anastomotic
leak can have devastating consequences
f) Intersphincteric resection (ISR): ISR is indicated for lesions < 1 cm
from the anorectal ring or lesions invading the internal sphincter but not the
intersphincteric plane or the external sphincter, as determined by preoperative
imaging. Following a proctectomy with total mesorectal excision (TME) and
ISR, intestinal continuity is restored with a coloanal anastomosis. The external
anal sphincter is preserved during ISR to ensure reasonable functional
outcomes (i.e., continence) after surgery.
 o Patients who undergo ISR generally have worse continence than those who
undergo conventional proctectomy with TME and a greater proportion of
ISR patients develop low anterior resection syndrome.

g) Abdominoperineal resection of the rectum (APR):

o Abdominoperineal resection and permanent colostomy was done for 80%
of rectal cancers 40 years ago but after introduction of TME, neoadjuvant
CRT, advanced staplers and robotics, APR is required in less than 10% of
cases in the current era.
o This operation is still required for some tumours of the lower third of the
rectum where at least 1 cm of negative distal resection margin is not
possible, sphincters are directly involved by the cancer and patients with
poor presurgical anorectal function.
o The rectum is mobilised down to the pelvic floor through an abdominal
incision. The descending colon is divided and brought out as a colostomy. A
separate perineal incision is then made to excise the sigmoid colon, rectum,
and anus. Traditionally, the procedure was performed by two surgeons
operating simultaneously, one via the abdomen and the other via the
perineum.
o During an abdominal perineal resection (APR), the last portion of the
rectum just above the anorectal ring and levator muscle should not be
dissected in a “coning” in fashion, but rather, a cylindrical approach should
be undertaken. The cylindrical approach requires a standard TME to the
level of the levators and a wide extralevator resection (ELAPE = Extra
levator abdominoperineal excision). ELAPE has been shown to improve
oncologic outcomes by reducing CRM positivity and minimizing the risk of
local recurrence in patients with low anorectal cancers.

h) Hartmann’s operation

o This is an option in elderly and frail patients in whom there is concern

about poor anal sphincter function and postoperative incontinence or the
viability of an anastomosis. Colorectal excision follows the same principles
as outlined above, but the rectal stump is stapled closed, and the proximal
colon exteriorised as a permanent end colostomy.
 h) Multivisceral resection / Pelvic exenteration:
When carcinoma of the rectum has spread to contiguous organs (T4b), a more
radical operation known as pelvic exenteration is performed with an aim to
achieve a R0 (microscopically negative) resection margin. Involved adjacent
organs should typically be removed en bloc with dissection beyond the TME
plane. Thus, in the male, in whom spread is usually to the bladder or prostate, a
cystectomy or prostatectomy may be required in combination with anterior
resection to achieve complete oncological clearance. In the female, the uterus
acts as an oncological barrier, preventing spread from the rectum to the
bladder. Accordingly, a hysterectomy can be undertaken in addition to excision
of the rectum.

7. Adjuvant chemotherapy:
Following transabdominal resection surgery, all patients who underwent neoadjuvant
chemoradiotherapy or short-course radiation therapy for locally advanced (T3/4 or
node-positive) rectal cancer receive four months of adjuvant chemotherapy, regardless of
the pathologic findings at the time of resection. Adjuvant chemotherapy should
typically begin within 8 weeks of radical resection. Oxaliplatin containing regimens like
fluorouracil plus leucovorin and oxaliplatin [FOLFOX] and capecitabine plus
oxaliplatin (CAPOX) are preferred.

8. Liver resection:
Liver metastases occur in up to 70% of Colorectal cancer (CRC patients), either
synchronously (25%) or metachronously (45%). Three decades ago, metastatic CRC had
a dismal 5-year survival below 3%; however, selective liver resection for patients with
isolated liver metastases showcased a notable 50% 5-year survival, highlighting its
potential benefits.

9. Follow-up:
After curative resection and completion of therapy, a history, physical examination, and
CEA determination is recommended every 3 months for the first 2 years, then every 6
months until the 5th year. Colonoscopy is recommended 1 year after surgical resection,
and repeated in 1 year if abnormal; otherwise, repeated in 2 to 3 years. For patients
without prior full colonoscopy (i.e., due to obstructing lesion), colonoscopy in 6
months is recommended.