Chapter 8: Colorectal Surgery

Introduction

Historically, investigation in colorectal surgery has focused on small, single-center series investigating optimal surgical techniques. Examples of such papers include reports on the “holy plane” in total mesorectal excision (see b, below), the Nigro protocol for squamous cell carcinoma of the anus (see a), and papers describing outcomes with various surgical techniques for inflammatory bowel disease. During the last decade, in an attempt to reduce postoperative length of stay, the research focus has shifted to the safety and outcomes of minimally invasive techniques in colorectal surgery. Results of these trials acknowledge the acceptability of laparoscopic-assisted resection for benign disease and for colon cancer, but potentially worse oncologic outcomes with this approach in cases of rectal cancer.

The last decade has also seen a growing movement to treat early rectal cancers with radiation and/or local excision, as an alternative to radical resection. Traditional proctectomy for the treatment of rectal cancer continues to generate controversy, given variable outcomes depending on surgeon experience and technique. Surgical treatment of diverticulitis continues to evolve, with management increasingly determined on a case-by-case basis. There are a multitude of clinical questions that remain to be answered, including the role of robotic surgery in colorectal operations, how we might improve rectal cancer outcomes, and whether radiation and/or local excision can safely replace radical resection for early rectal cancers. The following articles represent the best available data to inform current practice; however, any practitioner of colorectal surgery must review the literature frequently to keep abreast of this rapidly changing field.

a. Nigro Protocol

An evaluation of combined therapy for squamous cell cancer of the anal canal.

SYNOPSIS

Takeaway Point: Chemoradiation therapy is the treatment of choice for squamous cell cancer of the anal canal, with abdominoperineal resection (APR) reserved for patients with persistent or recurrent disease.

Commentary: Prior to this trial, APR was the traditionally accepted management strategy for squamous cell carcinoma of the anal canal, with a 10-year survival rate of 52%. In the post–World War I era, British physicians began using radiation therapy as an alternative treatment, but the practice was discontinued because of toxicity. In the intervening years, radiation techniques advanced, and Dr. Nigro reports on the results of 104 patients who underwent combined chemotherapy and radiation for anal squamous cell carcinoma. He demonstrates complete clinical and pathologic response in most patients, with a low rate of severe toxicity. Largely as a result of this study, the standard of care for squamous cell carcinoma of the anal canal is now fluorouracil (5-FU), mitomycin, and radiation, often referred to as the “Nigro protocol,” with abdominoperineal resection undertaken only for residual or recurrent disease, or for palliation.

ANALYSIS

Introduction: When this article was published, the standard of care for ...