Editorial
Surgical Trends in the Management of Rectal Cancer
Tejedor P and Khan JS*
Division of Colorectal Surgery, Queen Alexandra Hospital, UK
*Corresponding author: Khan JS, Division of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
Published: 18 Jul, 2018
Cite this article as: Tejedor P, Khan JS. Surgical Trends in
the Management of Rectal Cancer. Clin
Oncol. 2018; 3: 1500.
Editorial
Despite advances in chemoradiotherapy, surgery remains the main modality for the treatment
of resectable rectal cancer. The last decade has seen some significant technological advances and
treatment developments including better diagnostics, development of new surgical tools, and in
particular enhanced vision systems leading surgeons to the era of digital surgery.
“The surgeon” remains an important factor in the survival of rectal cancer patients. Good quality
surgery as a result of sound surgical technique leads to reduced local recurrence and improved
survival. The fundamental principles of Total Mesorectal Excision (TME) surgery postulated by
Bill Heald were to perform surgery in the true embryological planes, removing the whole rectum
and the intact mesorectum, enveloped by the mesorectal fascia [1]. This ensures that adequate
lymphadenectomy is performed without any risk of spillage of tumour cells, and will also prevent
collateral damage to pelvic organs including the neurovascular bundle.
The recent advances in technology and tools have allowed surgeons to potential apply minimal
access surgery and the laparoscopy for TME surgery. This technique initially has been difficult to
master, as it is associated with a longer learning curve, but surgeons with good experience and
structured training have shown that good quality laparoscopic TME is possible. However, in a
narrow pelvis, sometimes the dissection of the lower rectum can be difficult, and the exposure can
be a problem and finally stapling on the rectum can be challenging as well. Some of the inherent
difficulties of laparoscopic surgery such as 2D image, a fulcrum effect, limited access to marrow pelvis,
and amplification of tremor has been overcome by the increased use of robotic technology for TME
surgery [2]. Robots offer a 3D view, along with endowrist instruments and stability of the operating
platform. Thus, this control allows surgeons to replicate the principles of open TME surgery in a
minimal access fashion. There has been a significantly increased interest in the use of robotic sin
general surgery and nearly 12 new industry partners are now investing in developing and creating
new systems to launch over the coming years. Apart from improvements in surgical navigation, and
imaging overlay, there is hope to use artificial intelligence to a level where the surgeon may oversee
the performance of robotic platforms like the use of autopilot in airline industry.
These newer robotic technologies are not cheaper and the current systems are expensive to
buy and run, as the cost of consumables remains high. Endoscopic surgeons have discovered that
TME surgery can be performed from the anal route in almost a reverse fashion to the standard
TME surgery. This “bottom up” approach or Trans anal TME (TaTME) has become very popular
amongst surgeons as it allows overcoming the challenges of a difficult pelvis by operating in a
retrograde fashion using the current laparoscopic tools. These newer adoptions amongst surgeons
have resulted in almost a competition amongst different techniques. Surgical literature has been
recently bombarded with abstracts and case series and studies with the objective to compare robotic,
transanal and laparoscopic TME surgery. However, the technologies cannot fight one each other in
order to prove that one is better than the other [3,4].
Some randomized control trials supported the laparoscopic approach, whilst others still
recommended the open surgery [5-8]. A recent systematic review has shown that robotic procedures
are comparable to open and laparoscopic ones concerning oncologic outcomes [9]. So, at the
moment, no level I evidence exists which shows superiority of one technique over the other. A lot
of effort may be cored in setting up randomized control trials to get evidence in terms of comparing
these techniques but it does look very complicated to set-up a trial comparing open vs. laparoscopic
vs. TaTME vs. robotic surgery in these situations. Rectal cancer surgeons must not forget that the
most important thing, from the patient’s point of view, is the disease free survival and quality of life
after surgery. In the absence of strong evidence no recommendations can be made for the superiority
of one surgical approach over the other. One technique may produce excellent results in the hands
of one surgeon while the other may be the best option for a different surgeon. Surgeons should play
to their strengths and the only focus should be to get good oncological
outcomes with improved quality of life.
Depending on the circumstances, expertise and equipment
availability, one technique may be preferable than the other. It’s the
decisions that are more important than the incisions; surgeons will
choose to make in order to perform TME surgery. Good clinical
outcomes will be attained as long as Heald’s principles of TME
surgery could be followed.
We believe that these techniques complement each other,
rather than competing. There will be scenarios where perhaps two
approaches could be combined together. After a robotic TME, if a low
stapling is difficult or the tumour is very low, a transanal approach
may be more appropriate to perform a single end-to-end anastomosis
in those more challenging cases. In a laparoscopic TME the lower half
of the TME could be done with transanal technique and may be the
robot may prove to be a better tool for transanal TME.
A good knowledge of anatomy, sound surgical skills, following
oncological principles should result in a good specimen, who should
be continuously audited with the pathology and the clinical outcomes
after wards. Heald’s principles of TME surgery for rectal cancer still
hold strong and should be the prime focus of any surgeon dealing
with rectal cancer.
References
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- Jamali FR, Soweid AM, Dimassi H, Bailey C, Leroy J, Marescaux J. Evaluating the degree of difficulty of laparoscopic colorectal surgery. Arch Surg. 2008;143(8):762-7.
- Patel CB, Ragupathi M, Ramos-Valadez DI, Haas EM. A three-arm (laparoscopic, hand-assisted, and robotic) matched-case analysis of intraoperative and postoperative outcomes in minimally invasive colorectal surgery. Dis Colon Rectum. 2011;54(2):144-50.
- Park JS, Choi GS, Lim KH, Jang YS, Jun SH. Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of shortterm outcomes. Ann Surg Oncol. 2010;17(12):3195.
- Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;372(14):1324-32.
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- Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA. 2015;314(13):1356-63.
- Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. JAMA. 2015;314(13):1346-55.
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