Rectal cancer. Improvement of therapy with anterior resection or abdominoperineal excision

Abdominoperineal excision of the rectum has been the surgical treatment of choice for octal cancer of the middle and lower third for decades. However, subsequent to technical developments, particularly stapling instruments, s phincter saving procedures such as low anterior or intersphincteric resecti on superseded abdominoperineal excision in the majority of tumors of the mi ddle and even lower third of the rectum. Within the last seven years (1990- 1997), 253 patients with distal rectal cancer underwent surgery - in 204 pa tients surgery was carried out for the cure of malignancy, whereas in 49 pa tients surgery was performed for palliation. In the meantime, the rate of a bdominoperineal excision with permanent stoma was steadily decreased from 2 5 % (1990-1993) to 9 % (1993-1997). Concerning oncologic quality, sphincter saving resections showed evidence that cure rates (3-and 5-year survival) were not compromised by these techniques; conversely, sphincter saving rese ctions offered oncologic cure rates superior to abdominoperineal excision o f the rectum. Complete lymphadenectomy with high ligation of the inferior m esenteric artery and total mesorectal excision (TME) are fundamental compon ents of this approach. Moreover, the adverse effects of a permanent colosto my and the consecutively diminished quality of life following abdominoperin eal excision can be avoided in approximately 80 % of cases. In conclusion, at present 80-85 % of octal carcinomas of the middle or lower third can be surgically treated by sphincter saving low resections without compromising oncologic radicality.