Results of radical surgery for rectal cancer

This paper examines the hypothesis that a reduction in the distal mural margin during anterior resection for sphincter conservation in rectal cancer excision is safe, provided total mesorectal excision is undertaken with wash‐out of the clamped rectum. One hundred ninety‐two patients underwent anterior resection and 21 (<10%) patients underwent abdomino‐perineal excision (APE) by one surgeon (RJH). Anterior resections were classified as “curative” (79%) and “non‐curative” (21%); in the “curative” sub‐group <4% of patients developed local recurrence. The series was retrospectively analyzed for the effect of mural margins on local recurrence with 152 patients undergoing “curative” anterior resections and 40 patients undergoing “non‐curative” resections. In the 152 specimens from curative resections, 110 had a resection margin >1 cm and 42 had a resection margin <1 cm. Four patients developed local recurrence in the >1 cm margin group (95% confidence interval: 0.8%–7.8%) and no patients developed local recurrence in the ≤1 cm margin group (95% confidence interval: 0%–5.9%). In each patient with local recurrence a cause for failure was apparent. There was no statistically significant difference in local recurrence rate between the ≤1 cm margin group and the >1 cm margin group. A reduction in resection margin therefore did not compromise survival after anterior resection. The significance of lateral resection margins is discussed. The role of deep radiotherapy and cytotoxics are considered. However, in view of the low local recurrence rate that can be achieved by adequate surgery, it is the opinion of the author that radiotherapy and cytotoxics have little extra to offer in the management of cancer of the rectum treated by total mesorectal excision. Finally, the functional results following anterior resection and total mesorectal excision are analyzed and the refractory problem of anastomotic leakage is discussed.