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 has 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. (4)
Lower half of rectum is totally extraperitoneal and the absence of serosa below
the peritoneal reflection facilitates deeper tumour growth in the perirectal fat and
may contribute to higher rates of locoregional failure.

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.

SURGICAL ANATOMY OF RECTUM

“Doctors without anatomy are like moles: they work in the dark and their daily
tasks are mole hills” FRIEDRICH TIEDEMANN (1781–1861)”

• 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 is 12 cm long and lacks a true mesentery, haustrations, tinea coli and
appendices epiploicae. If one includes the length of the anal canal (4 cm from the
anal verge to the anorectal ring), then the rectosigmoid junction is at 16 cm from
the anal verge when examining an anesthetized patient in the left lateral position
with a rigid sigmoidoscope.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 1
 The distance of the lower edge of the
tumour from the anal verge is probably
the single most important variable that
aids the surgeon in the choice of
operation. 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 16 cm.

However, surgical decision making for

sphincter preservation is dependent
Distance of tumour from anal verge mostly upon the distance from the lower
measured by rigid sigmoidoscopy
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

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 2
 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 (12-16 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:

“Surgical technique is an important predictor of outcome for rectal

cancer and is intimately related to a clear understanding of the
anatomy of the rectum and its fascial relationships”
• 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.
Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 3
 • 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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 4
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.

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

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 5
 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.

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 6
 • 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 mesorectal fascia (MSF) (fascia propria)
T4b Tumour directly invading or adhering to other organs or structures

N0 No regional lymph node metastasis

N1 Metastasis to 1-3 regional lymph nodes
N2 Metastasis to ≥ 4 regional lymph nodes

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

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

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 7
patient. Symptoms associated with rectal cancer include bleeding per rectum, tenesmus,
early morning diarrhoea & increasing constipation.
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).

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.

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 8
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.

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 9
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.

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.

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 10
PET-CT

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.

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. Neoadjuvant
therapy is not considered for patients with upper 1/3rd rectal cancer. 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:
Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 11
 • 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 (a total of 50.4 Gy in 28
fractions over 5.5 weeks) 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 period 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

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 12
 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.
✓ 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 mechanical 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 (Polyethylene glycol) with an electrolyte solution (PEGLEC). The PEGLEC
Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 13
 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. PEGLEC
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:

o 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:

TOTAL MESORECTAL EXCISION:

o 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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 14
 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 downward spread
within the mesorectum is confined to a maximum distance of 2-3 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 3-5 cm beyond the distal edge of the primary
tumour. And for cancers in the middle and lower third of the rectum, Complete
removal of the mesorectum down to the pelvic floor (TME) is necessary.

RESECTION MARGINS:
o 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 negative
radial and distal resection margins (DRM) are critical. In situations where DRM
Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 15
 and radial margin are threatened, a neoadjuvant CRT or a TNT is administered so
that maximum tumour downstaging & downsizing is achieved, and a negative
margin resection (R0) is achieved.

o Radial margin: Radial margin clearance can be achieved with total mesorectal
excision (TME). The distance of the tumour 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.

LYMPHOVASCULAR PEDICLE LIGATION:

o 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 resections

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 16
7. TECHNIQUES OF TRANSABDOMINAL RESECTION SURGERIES:

A. ANTERIOR RESECTION:

✓ 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.
✓ 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:
Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 17
 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

✓ 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 divided with a
margin of 3-5 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.

✓ For tumours in the middle 1/3rd and lower 1/3rd of the rectum, a low anterior
resection is performed. Rectum is resected 2 cm distal to the tumour and total
excision of mesorectum is performed and gastrointestinal continuity is reestablished
by a colorectal anastomosis.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 18
✓ In very low rectal cancers (Tumour <2 cm from the anal ring or < 6cm from the anal
verge), only 1 cm distal resection margin is possible, and an ultra-low anterior
resection is done and CRA is performed at the level of pelvic floor with a double
stapling device.

Anterior resection syndrome:

o Bowel function after CAA following 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

Temporary diverting stoma

o A temporary diverting stoma should be constructed to protect an anastomosis in all
patents with anastomosis below the peritoneal reflection (< 8 cm from anal verge)
or at the level of pelvic floor and all patients who underwent preoperative pelvic
radiation (Long dose Chemoradiation).
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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 19
 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

B) 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 Alternatives to APR for patients with lower rectal tumour have evolved and include
the following:
✓ 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.
✓ 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.
o APR 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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 20
C. HARTMANN’S OPERATION

✓ 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.

D) 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

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 21
isolated liver metastases showcased a notable 50% 5-year survival. In patients of CRC
with an isolated liver and lung metastasis (M1a), if the primary rectal cancer is
resectable, curative resection of both primary and liver secondary is still possible with
reasonable survival.

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.

Compiled by Dr. Ch. Santhosh Babu, Associate professor of surgery, GMC Nalgonda pg. 22