Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

Abstract

Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the “bottom-to-up” approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

Comparison of surgical quality and long-term outcome between hybrid trans-anal total meso-rectal excision and laparoscopic total meso-rectal excision: a systematic review and meta-analysis

“…Quality of TME surgeries depends heavily on the integrity of resected mesorectum [26], and rectal surgery's higher demand on intra-operative visual field and quality of specimen prompted the rapid development of ta-TME [27]. The trans-anal procedure started directly from the otherwise most difficult part of TME surgeries, providing clearer field of view and broader space to maneuver.…”

Surgical Treatment of Low-Lying Rectal Cancer: Updates

“…Furthermore, the superiority of robotic surgery over laparoscopic surgery was not proven in the ROLARR trial [ 19 ]. As shown in previous studies, advanced surgical techniques could not ensure better oncological outcomes, but they can allow safe performance of deep pelvic dissections [ 1 , 46 , 47 ]. Although the anorectal function has been proved to recover better 1 year after robotic TME when compared to laparoscopic, open, or transanal approach, probably due to better visualization and preservation of pelvic neurovascular structures [ 48 ].…”

“…The symptoms are diverse, including increased bowel movement frequency, urgency, fecal incontinence, sense of incomplete emptying, and fragmentation. The leading causes of LAR are presumed to be anal sphincter damage during the operation, reduced neorectal compliance as a reservoir, altered motility of the neorectum possibly caused by denervation during deep pelvic dissection, and NCRT [ 47 ]. It has been speculated that the long duration between the creation of protective ileostomy and its reversal could worsen neorectal compliance and lead to LARS; however, recent studies confirm it was not a significant independent predictor of post-closure complications rate [ 84 ].…”

“…A Dutch TME trial showed overall sexual dysfunction in 76% of male patients and 62% of female patients. Voiding dysfunctions, including urinary incontinence, retention, urgency, and incomplete voiding, are known to be less severe than sexual dysfunctions, and the incidence has been reported to be > 30% [ 47 ].…”

The challenges in colorectal cancer management during COVID-19 epidemic

“…In brief, radiotherapy (45-50.4 Gy/25-28 F) and NACT (capecitabine or mFOLFOX6) could be chosen for mid-low advanced rectal cancer patients with T4 stage. And for rectal cancer patients with T3 stage, short-term radiotherapy with lower radiation dose (25 Gy/5 F) may be an option.The optimal timing for surgery and the "Wait and watch (W&W)" strategy for rectal cancer during COVID-19 epidemicAlthough total mesorectal excision (TME) has been used for a long time as a cornerstone for rectal cancer treatment, the concept of "W&W" has gained popularity in recent years, representing a divergence from the traditional treatment(36). Previous study has proved that about 15-30% of patients with rectal cancer treated with neoadjuvant treatment develop pathologic complete response (pCR)(37).…”