History

In 1908, investigating the pathogenesis of rectal cancer, Miles established the role of the lymphatic system in the spread of malignancy and emphasised the need for synchronous removal of the rectum and its "lymphatic drainage" with the abdominoperineal approach [1].

This event was supposed to be the beginning of state-of-the-art surgery of rectal cancer, though during the following 30 years the Miles operation played an insignificant role in the treatment of rectal adeno-carcinomas because of high operative mortality caused by imperfection of anaesthesia technique and peri-operative care [2]. Progress in medicine resulted in a decrease in post-operative deaths and allowed abdominoperineal resection (APR) to yield better long-term results as compared to trans-sacral procedures. Soon APR became the gold standard of treatment of rectal cancer [3].

Further investigation into the principles of spread of rectal adenocarcinomas [4] along with the wide use of stapler techniques and hand-suture colo-anal anastomosis made it possible to largely replace the operation that was "ideal" in the recent past. At the present time, APR is undeniably utilised for adeno-carcinoma of the lower third of the rectum, located in close proximity to the dentate line, which can also be involved in malignancy. The use of total mesorectal excision (TME) has enabled surgeons to substantially decrease local recurrence and to increase the five-year survival after APR, though the results obtained for the lower third of the rectum are still worse than those obtained for the middle and upper thirds [5]. The development of a nerve-sparing technique has brought about the improvement in urinary and sexual function outcomes of APR [6]. Nevertheless, the main drawback, abdominal colostomy, has not been eliminated. All the circumstances mentioned have determined the place of APR in the surgery of rectal cancer in the beginning of the 21st century.

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