Time for a renewed strategy in the management of rectal cancer: critical reflection on the surgical management of rectal cancer over 100 years.

Diseases of the Colon & ReCtum Volume 57: 3 (2014) although rectal cancer surgery has seen several milestones over the last century, the quest for the optimal approach for rectal cancer surgery seems to be far from over. William miles pioneered the modern concepts of rectal cancer surgery when he published in 1908 the outcome of a procedure he called ‘‘radical abdominoperineal resection’’ (aPR) to remove the rectum and the ‘‘upward zone of spread’’ with an ‘‘anatomically correct’’ resection. he proposed removal of the rectum through a combined abdominal and perineal approach to allow for removal of the cancer and associated lymph nodes en bloc. his overall recurrence rate was 29.5%, with its consequences in terms of poor quality of life and reduced survival. Despite the relative improvements in the oncologic outcomes by the miles operation, many surgeons felt, even at that time, that the miles procedure was associated with extensive morbidity, such as permanent colostomy, genitourinary dysfunction, and psychosocial implications. in 1948, Claude Dixon shifted the focus of rectal cancer surgery from aPR to sphincter-sparing procedures by introducing anterior resection, which became the standard of care for upper and middle rectal tumors. the interest in sphincter preservation even for tumors in the lower third of the rectum without compromising oncologic outcomes was started by sir alan Parks in the 1970s when he described coloanal anastomosis. this permitted lower third rectal tumors to be resected without the need for a permanent colostomy. heald and Ryall led the introduction of a major milestone in the surgical management of rectal cancer in 1986 when he published his results with a local recurrence rate of 5% using the concept of total mesorectal excision (tme), which entails resection of the tumor and mesorectum en bloc to the level of the levator muscles sharply under direct vision. the main focus around that time from the surgical community was, rightly, to reduce the incidence of local recurrence. therefore, this led to growing interest in the role of neoadjuvant chemoradiotherapy. the increasing use and experience with staging mRi scans allowed for judicious use of this modality, which resulted in low recurrence rates even in patients with locally advanced disease at the time of diagnosis. however, surgical resection for rectal cancer continued to have its inherent morbidity, and many patients who had their cancer treated had to live with the consequences of their successful treatment. the next breakthrough was the publication of the first series of laparoscopic colorectal resections in 1991, which included a mixture of colonic and rectal resections. this created a glimpse of hope and enthusiasm among surgeons, because they believed that the morbidity associated with colorectal surgery could be improved by reduction in the trauma of access when the laparoscopic approach is used. the mRC Conventional vs Laparoscopic-Assisted Surgery in Colorectal Cancer (ClassiC) trial demonstrated that, whereas laparoscopic colonic surgery is associated with improved short-term outcomes when compared with open surgery, this was not necessarily applicable to rectal surgery, because the laparoscopic group in the study had increased rates of positive circumferential resection (CRm) and increased rates of anastomotic leak, although neither reached statistical significance. it was also noted that conversion to open surgery was associated with an increased complication rate. the rate of conversion was 29%. the ClassiC trial, as well as other studies, demonstrated that laparoscopic rectal resection is associated with increased risk of sexual and urinary dysfunction, because 41% of men in the laparoscopic rectal surgery (lRs) group had sexual dysfunction after laparoscopic anterior resection in comparison with 23% in the open group, as well as increased anastomotic leak. most surgeons would argue that outcomes of the mRC ClasiCC trial should be interpreted with caution in view of the fact that the study design had set the Time for a Renewed Strategy in the Management of Rectal Cancer: Critical Reflection on the Surgical Management of Rectal Cancer Over 100 Years