Rectal Cancer

Abstract

THE SURGICAL management of rectal cancer has been a challenge from the time of Miles¹ to the present. The standard surgical approaches of abdominoperineal (AP) resection or anterior resection (AR) have produced disappointing results, both in local control and in overall survival. This has prompted the development of adjuvant strategies using radiotherapy, chemotherapy, or both to improve outcomes. In 1978, one of us (R.J.H.), working in Basingstoke, England, questioned the traditional operations and began to develop the procedure that is now known as total mesorectal excision (TME) in an effort to reduce the rate of local recurrence (LR) of rectal carcinoma in the pelvis. Refinements of precise surgical dissection from above developed after the introduction of surgical stapling for the anorectal muscle tube. The procedure was developed with an awareness of the importance of complete excision under direct vision of the envelope of lymphovascular fatty tissue surrounding the rectum and its mesorectum. It was postulated that LR was more a result of leaving mesorectal residue than of the inherent nature of rectal cancer to spread beyond the confines of perimesorectal dissection. The results of these efforts yielded the lowest rate of LR yet published in the literature^2-4 and challenged the surgical community worldwide to recognize the importance of meticulous dissection in the management of this disease. The trend toward the acceptance of TME^5-11 attests to the validity of the original concept and sets a new gold standard that future adjuvant strategies must meet. We review the results obtained in 519 consecutive operations, mostly at the Colorectal Research Unit, The North Hampshire Hospital in Basingstoke between 1978 and 1997.