Current Concepts in Rectal Cancer

Abstract

Since the first recorded surgical resection for rectal cancer in 1826 by Jacques Lisfranc, 1 the management of rectal cancer has evolved remarkably with dramatic improvements in local recurrence and mortality. Surgical resection is the only proven curative treatment of rectal cancer and the important advances in care have involved improvements in surgical techniques. Most of these improvements during this time period resulted from a better understanding of the anatomy and pathology of rectal cancer. It is important to be familiar with these important advances in rectal cancer treatment to fully understand the current methods of treatment.Historical Overview: From Miles' Abdominoperineal Resection to Today's Sphincter-Preserving Techniques Rectal Resections before MilesGiovanni Morgagni in the early 18th century was the first to propose rectal resection as a treatment for cancer. 1 However, it took over a century before the first successful rectal resection was performed. Over the years, there have been constant changes in the approach used by surgeons to perform a rectal resection.Rectal resections were first performed using a perineal approach as described in 1826 by Jacques LisFranc. 1,2 He operated in the era before anesthesia and proper antiseptic techniques. Since inadvertent entry into the peritoneal cavity could prove lethal, he chose the perineal approach to evert the rectum and perform a limited resection below the peritoneal reflection. A limited amount of rectum was resected with this approach and no attempt was made to purposely include the mesorectum and draining lymph nodes. 2 Success at that time was based upon whether the patient survived to leave the hospital, and so the risk of local recurrence had very little influence. With the advent of anesthesia and aseptic techniques, operations could now be performed that would provide for a more radical resection. Paul Kraske developed a technique similar to Kocher's technique, where he would incise and detach the left side of the coccyx and sacrum to provide more exposure. This exposure allowed him to resect the rectal cancer with ½ inch margins on either side of the rectum. The proximal bowel would then be pulled down and sutured to the anal sphincter complex. However, this "sacral anus" was difficult for the patient to manage. 1,3 Carl Guessenbauer performed the first transabdominal rectal resection and with closure and colostomy in 1879. This procedure would be later popularized by Henri Hartmann for the purpose of treating diverticulitis. 4 Vincent Czerny is credited with performing the first combined abdominal and perineal approach. This combined approach was never intended but was performed only after an unsuccessful attempt at resection through the perineal approach. 1 In Vogel's review of 1,500 cases performed by 12 of the most prominent 19th century surgeons including Billroth, Kocher, Kraske, and Czerny there was a 21% operative mortality rate with a high (80%) recurrence rate. 3 Surgery certainly had progressed beyond LisFranc's perineal res...

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