Perianal Technique for Selected Cases of Early Rectal Cancer

High recurrence rates - T1 18%, T2 47% - are described in all of these approaches, and survival varies in T1 from 72 to 90% and in T2 tumours from 55 to 78%.

A number of different methods are currently available for the treatment of rectal tumours. Anterior resection or abdominoperineal resection with total or proximal mesorectal excision is the gold standard for rectal cancer, as these methods offer the best chance of cure. Perianal local resection under direct vision may be an appropriate alternative for patients with early rectal cancer who are unfit for major resec-tional surgery and is the treatment of choice for rectal adenomas that are too large for coloscopic excision. Advantages of this technique are the avoidance of the significant morbidity and mortality of major surgery, avoidance of stoma and a short hospital stay. After local excision patients may still receive adjuvant therapy when necessary and proctectomy remains an option for local recurrences or excised lesions that show unfavourable pathology. Alternatives to perianal local resection include transanal endoscopic microsurgery (TEM), Mason's technique of trans-sphincteric approach and Salvati's method of transanal resection.

The beginning of the intervention does not differ from that of transanal polypectomy. A series of sutures are placed around the periphery of the tumour, as just described. The excision should include at least 2 cm from the macroscopic edge of the tumour to ensure complete removal of tumour. The mucosa and submucosa are divided peripherally around the lesion using diathermy. All submucosal vessels must be secured during division of the mucosa and submucosa in order to maintain a dry field. If the tumour has been correctly staged, complete clearance can be achieved by excision of a disc of full-thickness rectal wall. Indeed, if perirectal fat is not observed, the excision has not been sufficiently deep to achieve adequa te clearance. It is often helpful to place a series of stay sutures beyond the resection margin to facilitate the closure of the defect once the tumour has been removed. Once the lesion has been removed completely, the defect in the rectal muscle should be closed transversely using continuous resorbable monofilament suture 2/0. The mucosa is closed with a running resorbable monofilament suture 3/0.

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