Surgery

The surgeon should remove the primary tumour with adequate margins: R0 are complete tumour resections with all margins negative; R1 are incomplete tumour resections with microscopic involvement of a margin; and R2 incomplete tumour resections with gross residual tumour.

Patients affected by rectal cancer are submitted to one of the following surgical procedures: transanal procedures in early rectal cancer; low anterior resection or colo-anal anastomosis; and APR in both cases, using the total mesorectal excision technique.

Sacrifice of anal sphincter and a permanent stoma may adversely affect the quality of life of some patients but an inappropriate sphincter-sparing procedure may result in excessive stool frequency and faecal incontinence.

The total mesorectal technique consists of sharp dissection of the predominantly avascular plane between the parietal and visceral pelvic fascia. Anteriorly, the specimen contains the intact Denonvil-liers's fascia and the peritoneal reflection. Autonom-ic nerve preservation requires identification and sparing of the pre-aortic superior hypogastric plexus as well as the bilateral hypogastric nerves to form the inferior hypogastric plexus anterolaterally on both sides [17].

Dutch surgeons showed that standardised application of this technique permits reduction of the incidence of local recurrence (local recurrence 8.2%) omitting adjuvant therapy [18].

The total mesorectal excision technique permits correct valuation of lymph node status and radial margin. A positive radial margin is a negative prognostic indicator with sensitivity, specificity and positive predictive values of 92, 95 and 85% respectively [19].

Locally advanced cancer should be removed by en bloc resection including any adherent tissues, as it is not possible to differentiate macroscopically between adherence of malignant invasion or inflammatory reaction. En bloc resection with clear margins of adjacent organs locally infiltrated by cancer can achieve similar rates of survival as patients with tumour T3 [20, 21].

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