Tumour Variables

APR of the rectum is conventionally performed when the tumour is located 0-5 cm from the perianal skin. However, APR (with permanent stoma) is not always the appropriate operation. In this case, when a low-dimensional tumour (less than 2 cm in diameter) is characterised by a high or good degree of differentiation, its invasion does not exceed the submucous layer, and the surgeons have no information on whether there is lymphovenous invasion, it is reasonable to apply various local procedures (transanal excision, TEM, diathermocoagulation via anoscope, etc.). At the same time, the T2 or T3 tumours without involvement of internal sphincter and longitudinal muscle in case of highly and well differentiated ade-nocarcinomas located 1-2 cm from the dentate line cannot be considered as an implicit indication for APR. Such tumours should be judged from the view point of the possibility of implementing resection of the rectum with subsequent formation of either ultralow stapled colorectal or hand-sutured colo-anal anastomosis. Therefore, the surgeon should make the final decision of operative technique upon completion of TME, being certain of the absence of macro-and microscopic symptoms of cancer invasion in the circular and distal margin of expected resection ("rectum neck" in the area of junction to levator). An impossibility of providing an uninvaded margin of any of the lines of resection can serve as an indication to perform APR. Invasion of dentate line or a free margin less than 1 cm is an indication for APR. However, there have recently been discussions of the possibility of using the intersphincteric or "close-shaved" approach to treat such patients when a portion or the whole of internal sphincter is resected [8-10]. Control over continence after such operations is accomplished by the residual portion of anal sphincter in combination with the reservoir technique. It is undeniable that cancer of the low rectum (prevailing situation) can serve as an indication for APR when the parietal fascia are involved as well as when there are symptoms of lymphatic spread (finger investigation, TRUS, MRT), regardless of the distal margin of the tumour from the dentate line.

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