Chapter 40

At the beginning of the 21st century, rectal cancer continues to be a significant medical and social problem. Currently, there are approximately 149,000 cases of colorectal cancer diagnosed in the United States each year. Adenocarcinoma of the rectum accounts for nearly 30% of these cancers. This translates into 41,000 new diagnoses of rectal cancer each year and greater than 10,000 deaths attributable to this disease within the same time period.1

The history of modern rectal cancer resection dates back to 1884, when Czérny described the first abdominoperineal resection (APR). In 1885, Kraske pioneered the transsacral approach of rectal resection and anastomosis. In 1908, Miles improved on the APR by understanding that there was a “zone of upward spread.”2 He emphasized the importance of performing a wide perineal excision. Furthermore, he advocated removal of the rectum with a high ligation of the superior hemorrhoidal artery as well as excision of the abdominal attachments of the rectum and the iliac lymph nodes. Despite the improvements in oncologic resection, operative mortality in Miles' first series exceeded 42%. Over the next 80 years through the late 1980s, mortality and morbidity for rectal cancer surgery improved markedly in pace with improvements in intra-, peri-, and postoperative care. Unfortunately, there were few, if any, advancements in oncologic techniques during this period. Then, in the late 1980s, William Heald described and began popularizing total mesorectal excision (TME) for carcinoma of the rectum.3 In this technique he advocates using sharp dissection to perform the complete excision of the mesorectum and its associated lymphatics along the subtle fascial planes that encompass the rectum. Moreover, Heald described a “zone of downward spread” within the mesorectum that requires complete excision in order to reduce local recurrence. Finally, local excision of small rectal cancers has been used for a 100 years in selected patients. More recently, local excision is being combined with neoadjuvant and adjuvant chemoradiotherapy to maximize local control with a minimally invasive approach.

In Western industrialized nations the average lifetime risk for an individual to develop colorectal cancer is approximately 6%. This risk increases two- to fourfold if the patient has a personal history of a first-degree relative with colorectal cancer. Inflammatory bowel disease (IBD) is another risk factor. In the first 10 years after the initial diagnosis of ulcerative colitis (UC), the incidence of colorectal cancer ranges from 2 to 5%; however, this risk increases 1% for each year of disease thereafter. Pancolitis is associated with both an earlier and an increased risk for colorectal cancer when compared to left-sided colitis alone. For all patients with UC, the cumulative risk for colorectal cancer at 25 years is 25%. Screening the colon yearly starting at 10 years after the diagnosis with colonoscopy and multiple biopsies in four quadrants every 10 cm from the cecum to the distal rectum is used to predict when a patient is at risk for developing colorectal cancer. If high-grade dysplasia is detected in ...

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