A Decade of Advances in the
Operative Management of Rectal Cancer

Warren Enker, M.D.
Chief, Colorectal Surgery
Beth Israel Medical Center

In the operative treatment of rectal cancer there are three major goals:

- Cure

- Prevention of local pelvic recurrence
- Reduction of morbidity associated with the consequences of surgery (sphincter preservation, avoiding a permanent colostomy, preservation of normal anorectal, urinary and sexual function)

Traditional teaching and current widespread practice suggest that any rectal cancer within reach of any examining finger be treated by abdominoperineal resection (removal of the entire rectum with establishment of a permanent colostomy).

When surgery is performed according to the standard or conventional method the pelvis is dissected bluntly, without regard for planes of anatomy. The result is not only inadequate cancer resection (removal), but the avulsion of and destruction of the nerves which control both sexual and urinary functions which pass immediately around the rectum.

The sum total of this experience is that the patient can expect a poor cancer operation, a permanent colostomy, impotence, and urinary disturbances, in addition to a local recurrence rate of 30% largely due to the inadequate removal of all cancer. The implications of this recurrence are poor survival (fatality in nearly 100% of cases), pain and suffering due to the recurrent cancer invading nerves in the pelvis, multiple hospitalizations, and major societal costs related to lost time from work, disability, medical care and death. Additionally, the high incidence of local failure has prompted the widespread use of radiation and chemotherapy after standard surgery. Both treatments are costly and carry their own rates of complications and consequences (e.g. poor rectal functions).

Over the decade, major progress on all of these fronts has been achieved by a few surgeons who have been dedicated to the treatment of rectal cancer in major centers around the world, most notably in the UK, the US (New York) and Japan and more recently in the Netherlands, Norway and Sweden.

These surgeons are operating on the principle of using sharp dissection (as opposed to blunt) along definable planes of anatomy, resecting the entire cancer including the rectum and surrounding fat where the lymph nodes are located. These surgeons have consistently reported survival rates of 75% (compared with 45%), pelvic recurrence of 5-8% (compared to traditional 30%) and the ability to enhance sphincter preservation. In recent years, attention to the anatomy of the pelvic autonomic nerves has lead to the overall preservation of sexual and urinary function in 85% or more of men and women who were sexually active prior to surgery (the average age of patients with rectal cancer is 62+).

The use of a permanent colostomy has been limited to those patients who have a rectal cancer in the lowest reaches of the rectum, where no opportunity exists to save the anal and low rectal sphincters.

This new technique is known as Total Mesorectal Excision (TME), and is accompanied today
at Beth Israel Medical Center, by Autonomic Nerve Preservation (ANP). The differences in outcome are apparent from the following estimates observed in hundreds of patients so treated.