low anterior resection for rectal cancer

Preoperative therapy The preoperative type of treatment is based on tumor localization and locoregional involvement. Based on the Dutch TME Trial the next preoperative treatment is advised: Predicted circumferential resection margin<2mm: chemoradiation (for 6 weeks and another 6 weeks to allow downsizing) T4 tumors (pelvic, urogenital or sacral involvement): chemoradiation (as above) Predicted circumferential resection margin >2mm: short-term radiation 5 x 5 Gy (in 5 days)

Anastomosis
A colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results. Because of a reduction in complexity and operating time, a side-to-end anastomosis could be recommended.

Low tie versus high tie
Neither the high tie strategy nor the low tie strategy is evidence based. The low tie strategy is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. Therefore, in rectal cancer surgery low tie should be the preferred method.

Adjuvant therapy
There is no evidence that adjuvant therapy improves outcome or survival for rectal cancer. Because of its significant beneficial effect in colon cancer it might be considered for patients that are motivated and with a reasonable physical state, which had a tumor >T3 or N1, or as part of a trial.

Literature
1. Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial.Machado M et al. Ann Surg. 2003 August; 238(2): 214–220
2. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review.Lange M et al. Dis Colon Rectum. 2008 Jul;51(7):1139-45
3. Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group.Kapiteijn E, Kranenbarg EK, Steup WH, Taat CW, Rutten HJ, Wiggers T, van Krieken JH, Hermans J, Leer JW, van de Velde CJ. Eur J Surg. 1999 May;165(5):410-20.