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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Radical resection of rectal cancer

Radical resection of rectal cancer
Authors:
Ronald Bleday, MD
David Shibata, MD
Section Editor:
Martin Weiser, MD
Deputy Editor:
Wenliang Chen, MD, PhD
Literature review current through: Jan 2024.
This topic last updated: Feb 23, 2023.

INTRODUCTION — Surgery is the cornerstone of curative therapy for rectal adenocarcinoma. Depending upon the clinical stage, size, and location of the primary tumor, a rectal cancer can be excised locally or radically. A local excision is usually performed transanally. A radical excision is performed transabdominally with either a sphincter-sparing procedure such as low anterior resection or an abdominoperineal resection. Rectal cancers that have invaded adjacent organs may require a multivisceral resection. (See "Surgical treatment of rectal cancer".)

In this topic, we review the radical resection of rectal cancer, including surgical anatomy, principles, and approaches (eg, open versus laparoscopic). Specific techniques are discussed in other dedicated topics:

●(See "Transanal endoscopic surgery (TES)".)

●(See "Abdominal perineal resection (APR): Open technique".)

●(See "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy".)

Diagnosis, staging, and nonsurgical treatment of rectal cancer can be found elsewhere:

●(See "Clinical presentation, diagnosis, and staging of colorectal cancer".)

●(See "Pretreatment local staging evaluation for rectal cancer".)

●(See "Overview of the management of rectal adenocarcinoma".)

SURGICAL ANATOMY

Rectum — The rectum is the continuation of the sigmoid colon leading to the anal canal. It is 12 to 15 cm in length and lacks taeniae, epiploic appendices, haustra, and a well-defined mesentery (figure 1) [1]. In women, the anterior rectum is in close proximity to the posterior vagina and uterine cervix (figure 2 and figure 3 and figure 4). In men, it is behind the bladder, vas deferens, seminal vesicles, and prostate (figure 5).

Although the precise description of the upper and lower limits of the rectum varies between anatomists and surgeons, it is generally accepted that the upper (proximal) limit of the rectum is at the rectosigmoid junction. The lower (distal) limit of the rectum is at the dentate line, which is located in the middle of the anal canal (figure 6). The dentate line is also the point at which the columnar mucosa of the rectum transitions to the squamous mucosa of the anus.

The upper limit of the rectum is defined operatively as where the taeniae coli of the sigmoid colon splay and become indistinct. Endoscopically, the upper limit of the rectum is defined as 15 cm from the anal verge on rigid proctoscopic examination [2]. Radiographically, the sacral promontory was generally regarded as the upper limit of the rectum. Alternatively, the point of the sigmoid takeoff (ie, the junction of the sigmoid mesocolon and mesorectum) as seen on cross-sectional imaging can be viewed as the upper limit of the rectum [3].

The location of a rectal cancer is identified by its distance from the anal verge rather than the dentate line. Low (distal) rectal cancers are located 4 to 8 cm from the anal verge, middle rectal cancers 8 to 12 cm, and upper (proximal) rectal cancers 12 to 15 cm [4]. The anal canal is 0 to 4 cm from the anal verge (figure 7). However, surgical decision making for sphincter preservation is dependent mostly upon the distance from the lower border of the tumor to the top of the anorectal ring (ie, top of the sphincter complex) rather than the anal verge.

The rectum has three lateral curves corresponding to the valves (folds) of Houston (figure 1) [5]. The upper and lower curves are convex to the right, and the middle is convex to the left. Once the rectum is mobilized, these valves are no longer present and are responsible for the increase in length gained during the surgical dissection.

The rectum is typically located below the peritoneal reflection [6]. The posterior rectal wall, which is close to the sacral hollow, is entirely extraperitoneal. The upper rectum is invested by peritoneum anteriorly and laterally, and the middle rectum is invested by peritoneum only anteriorly (figure 8).

The fascia propria is an extension of the pelvic fascia and encloses the rectum, adipose tissue, blood, and lymphatic vessels. It is more pronounced laterally and posteriorly and forms the lateral ligaments of the rectum (figure 9). In 25 percent of patients, the lateral ligaments contain branches of the middle rectal artery and venous plexus [1].

The rectum is not suspended by a true mesentery (ie, two layers of peritoneum that suspend an organ). The "mesorectum" is perirectal areolar tissue that is thicker posteriorly and contains the terminal branches of the inferior mesenteric artery (figure 10).

The rectum occupies the sacral concavity and ends 2 to 3 cm proximal to the tip of the coccyx. The presacral fascia covers the concavity of the sacrum and coccyx, presacral nerves, middle sacral artery, and presacral veins. This plane should not be violated during the pelvic dissection, as life-threatening hemorrhage from the presacral venous plexus can occur (figure 11). (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Presacral bleeding'.)

The anatomy of the anal canal, including the ischiorectal fossa and anal sphincters, is reviewed separately. (See "Operative management of anorectal fistulas", section on 'Anorectal anatomy'.)

Arterial blood supply — The blood supply enters the rectum posteriorly. The upper rectum is supplied by the superior rectal artery (SRA), a branch of the inferior mesenteric artery (IMA) (figure 12). The middle and lower rectum are supplied by the middle rectal artery and inferior rectal artery, respectively, which branch from the anterior division of the internal iliac artery and/or the pudendal artery (figure 12).

Venous and lymphatic drainage — The pathways for the lymphatic and venous drainage of the rectum are cephalad and lateral (figure 13 and figure 14 and figure 15) [7-9]. The lymphatic drainage of the upper two-thirds of the rectum is along the pathway of the superior hemorrhoidal vein, cephalad to the inferior mesenteric nodes, and the paraaortic nodes [1]. The lymphatic drainage of the lower third of the rectum is cephalad as well as lateral along the middle hemorrhoidal vessels to the internal iliac nodes. There are no communications between the inferior mesenteric and internal iliac lymphatics [8]. In women, lymphatic drainage above the dentate line also includes the posterior wall of the vagina and reproductive organs [1]. Below the dentate line, the drainage is along the inferior rectal lymphatics to the superior inguinal nodes and along the pathway of the inferior rectal artery.

Innervation — All pelvic nerves lie in the plane between the peritoneum and the endopelvic fascia and can be injured or transected during a rectal dissection.

The preganglionic fibers via the sympathetic nerves follow the branches of the IMA and the SRA to the left colon and upper rectum (figure 16). The presacral nerves, which are a fusion of the aortic plexus and lumbar splanchnic plexus, innervate the lower rectum [1]. Just below the sacral promontory, the presacral nerves form the hypogastric plexus. The main hypogastric nerves enter the rectum laterally and carry sympathetic innervation from the hypogastric to the pelvic plexus, located on the lateral side of the pelvis adjacent to the lateral stalks, at the level of the lower rectum.

The parasympathetic plexus emerges through the sacral foramen and joins the sympathetic hypogastric nerves at the pelvic plexus. Postganglion parasympathetic and sympathetic fibers are distributed to the left colon and upper rectum via the inferior mesenteric plexus and directly to the lower rectum and upper anal canal.

PRINCIPLES OF RADICAL RESECTION — All curative surgical treatments must include a wide resection of the rectal cancer to histologically negative margins. For transabdominal radical resections, such as low anterior resection (LAR) or abdominoperineal resection (APR), it is also crucial to perform a total mesorectal excision (TME) and an adequate lymph node dissection. Whenever feasible, the patient's intestinal continuity should be reestablished to preserve fecal continence.

Total mesorectal excision — Total mesorectal excision (TME) is the standard technique of removing perirectal tissue when performing radical rectal cancer surgery (LAR or APR). TME employs a precise, sharp dissection between the visceral and parietal layers of the endopelvic fascia to ensure en bloc removal of the perirectal areolar tissue, including the lateral and circumferential margins of the mesorectal envelope, lymphatics, and vascular/perineural tumor deposits with the primary rectal cancer (figure 17). TME should be performed for all patients undergoing radical surgical resection of mid- and low rectal cancers and results in a complete or near-complete mesorectal excision; the quality of TME resection should be documented in the pathology report in a synoptic format [10].

Rectal cancer cells spread downward within not only the mucosa and muscularis propria (ie, mural spread) but also the mesorectum, which is the peritoneal investment of the upper rectum. In two studies, tumor implants were not seen beyond 4 cm distally from the primary T3/4 tumors or beyond 1 cm distally from the primary T1/2 tumors [11-13].

Thus, 5 centimeters of mesorectum beyond the primary tumor should be removed with a TME [14]. Given that the rectum is 12 to 15 cm long, a complete removal of the mesorectum down to the pelvic floor is only necessary for cancers in the middle to lower third of the rectum [2]. For cancers located in the upper rectum, the mesorectum only needs to be excised to a level of 5 cm below the primary tumor.

TME is associated with improved local control and better survival based on observational data. The local recurrence rates after radical resection with TME ranged from 4 to 7 percent [15-19]. In comparison, the local recurrence rates of the same procedures without TME ranged from 14 to 45 percent, depending upon whether or not adjuvant therapy was used [20-22]. Improved local control appears to have translated into better survival [23,24]. (See "Adjuvant therapy for resected rectal adenocarcinoma in patients not receiving neoadjuvant therapy", section on 'Patients undergoing total mesorectal excision'.)

TME also preserves the autonomic nerves and reduces the risk of presacral bleeding. Preservation of the pelvic autonomic nerves reduces the risk of postoperative genitourinary dysfunction [25]. (See "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery", section on 'Genitourinary complications'.)

Transabdominal TME — For radical resection of rectal cancer, a standard TME can be performed transabdominally via either open, laparoscopic, or robotic approaches. The techniques of laparoscopic/robotic TME are illustrated in this video and discussed in another topic (movie 1). (See "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy", section on 'Total mesorectal excision and rectal transection (with video)'.)

Transanal TME — In experienced centers, TME has also been attempted transanally, particularly for distal rectal tumors in male patients with obesity who have a narrow pelvis [26-28]. Because the distal margin is assessed precisely from the beginning of the procedure, transanal TME (TaTME) has the potential to define the resection margins more clearly than standard transabdominal TME. However, TaTME remains an investigational technique.

A randomized trial of about 100 patients reported lower conversion rates with laparoscopic TaTME than laparoscopic standard TME (2 versus 11 percent) [29]. The complication and local recurrence rates (1.8 versus 6.1 percent) were comparable, albeit at a short median follow-up of 39 months.

Several systematic reviews of TaTME also reported shorter operative times, lower conversion rates, and lower positive circumferential radial margin rates than laparoscopic TME [30-32]. However, intraoperative complications such as injuries to the urethra, bladder, vagina, and rectum [28,33], as well as carbon dioxide embolism, have occurred with TaTME [34]. One study reported higher incidence and severity of low anterior resection syndrome (LARS) after transanal compared with standard TME [35].

Whereas studies with a follow-up of up to 29 months showed that TaTME had a comparable local recurrence rate and survival rate to standard TME [27,36-38], a Norwegian series of 110 TaTME procedures reported a local recurrence rate of 9.5 percent after a short median interval of only 11 months, leading to a moratorium on TaTME in that country [39] and a pause in Great Britain [40]. A subsequent study from an international registry of 2803 patients reported a lower local recurrence rate of 4.8 percent (95% CI 3.8-5.8 percent), a disease-free survival of 77 percent, and an overall survival of 92 percent at two years [41].

Given that TaTME has a learning curve of about 40 to 70 cases [42,43], it should currently only be performed at high-volume centers by experienced surgeons [44]. Given the additional resources, steep learning curve, and parity of outcomes, it does not make sense for most centers to adopt this technique. Transabdominal TME remains the standard treatment for most patients with rectal cancer. How to help novice surgeons ascend the steep learning curve and avoid major complications remains to be seen [45].

Resection margins — The primary goal of surgery for rectal cancer is to achieve histologically negative proximal, distal, and radial margins, as discussed below.

Proximal margin — A minimum negative proximal margin of 5 cm is required to remove draining lymphatics and assure an anastomosis to well-vascularized bowel [14]. Unlike the distal margin, a 5 cm proximal margin is technically easy to achieve, especially if the splenic flexure has been mobilized.

Distal margin

●For more proximal, upper rectal cancers, tumor-specific mesorectal excision with perpendicular transection of the mesorectum leaving a 5 cm distal margin distal to the tumor is acceptable.

●For cancers located above the distal mesorectal margin, the minimum recommended negative distal margin is 2 cm for most LARs performed in conjunction with a TME [2,46,47].

●For cancers located at or below the distal mesorectal margin, a 1 cm negative distal margin in conjunction with a TME may be acceptable [48], particularly in the setting of neoadjuvant chemoradiation therapy [49,50].

●Failure to achieve this 1 to 2 cm gross negative distal margin is an indication to convert from an LAR to an APR, which extends the distal margin to the anus. (See "Abdominal perineal resection (APR): Open technique".)

Radial margins — In rectal cancer surgery, the circumferential radial margins (CRMs) are equally as important as the distal margin. A histologic CRM of greater than 1 mm is required. A positive CRM is an independent predictor of local recurrences and inferior survival [15,51-55].

However, in one large cohort study, as many as 17 percent of patients undergoing rectal cancer surgery had a positive CRM [56]. A positive CRM is more likely when tumor is present within 1 mm of the mesorectal fascia [57] and/or when an inappropriate dissection plane within the mesorectum other than the TME plane is dissected [15].

Vascular invasion, particularly along the branches of the middle rectal artery, is a frequent source of positive radial margins [58,59]. In those cases, resection plane must be extended beyond the level of involvement.

Vascular ligation — Removal of the blood supply and lymphatics of the origin of the superior rectal artery by ligating the inferior mesenteric artery (IMA) below the origin of the left colic artery (low tie technique) is typically appropriate for rectal cancer resection [2].

Ligation of the IMA at the aorta with resection of associated lymph nodes (high tie technique) may be indicated in selected patients when clinically suspicious lymph nodes are present at the level of the IMA or to provide mobilization to afford adequate length for a tension-free anastomosis.

Compared with the high tie technique, the low tie technique had no worse outcomes in blood loss, operative times, defecatory function, postoperative complications including anastomotic leaks, lymph node yield, or survival and better preserved genitourinary and sexual function [60-67].

Lymph node dissection — Lymph node dissection is performed for the purposes of staging, local control, and interruption of the metastatic cascade. In most rectal cancer surgeries, lymph node dissection is performed with vascular ligation. (See 'Vascular ligation' above.)

Although the exact number of lymph nodes required for accurate staging of rectal cancer has not been determined, a benchmark of 12 lymph nodes has been adopted as a quality metric for colorectal cancer surgery by the American College of Surgeons, the College of American Pathologists, the National Comprehensive Cancer Network (NCCN), and the American Association of Clinical Oncology (ASCO) [68-70]. However, the use of neoadjuvant chemoradiation has been shown to reduce the number of lymph nodes that can be retrieved from the surgical specimen [71-75].

Lateral pelvic lymph node dissection — While TME addresses the main lymphatic route of the rectum, the distal anorectal segment is additionally drained by the internal iliac route via the middle rectal and pudendal vessels [76]. Progression of advanced rectal cancer along the lateral rectal pedicles may lead to lateral spread of the disease, affecting lymph nodes of the pelvic side wall [58,59].

Lateral (or extended) pelvic lymph node dissection removes the nodal compartment along the common iliac, internal iliac, and obturator arteries. Unlike TME, whether to routinely perform a lateral pelvic lymphadenectomy in rectal cancer surgery varies by geographic location. As an example, the Japanese Society for Cancer of the Colon and Rectum guidelines for the treatment of colorectal cancer recommend lateral pelvic lymph node dissection for T3/T4 low rectal cancers below the peritoneal reflection [77-79].

For the Western patient population, who would routinely receive neoadjuvant chemoradiation therapy for lower rectal cancer, routine lateral pelvic lymph node dissection is not typically required in the absence of a clinically positive lymph node in that compartment [2,80]. Nevertheless, since recurrence in the lateral compartment may be difficult to salvage, ipsilateral lateral pelvic lymph node dissection is indicated for clinically positive lateral pelvic nodes [81-83].

The definition of an "enlarged" or positive lateral lymph node has not been standardized. Until a consensus is reached, we suggest that surgeons follow protocols of their local institution as neoadjuvant therapy for low rectal tumors varies significantly between geographic locations. Furthermore, lymph node size should not be regarded as an absolute indication for lymphadenectomy but rather as a continuous variable: as the lymph node size increases, so does the risk of it being malignant.

At the authors' institutions, we do our best to characterize any suspicious lateral nodes prior to neoadjuvant therapy with magnetic resonance imaging (MRI). Although positron emission tomography (PET) scan and biopsy can be occasionally used, they are of a lower yield. In patients with low rectal tumors, factors associated with malignant lymph nodes include being in the obturator/internal iliac location and greater than 7 mm (8 mm at some institutions [84]) in the short axis [81,85].

Following neoadjuvant therapy, we assess the lateral nodes in question for any interval growth (persistence versus stability versus shrinkage) and compare their treatment response to mesorectal lymph nodes. The repeat MRI should be performed in no earlier than six weeks. When a suspected malignant lateral lymph node persists despite neoadjuvant therapy (eg, short axis >5 mm [4 mm at some institutions]), we restage, and in the absence of distant metastases, we advocate for formal lateral pelvic node dissection of the affected lymph node basin at the time of TME, rather than "berry-picking" only the suspicious nodes [86,87].

Although enlarged internal iliac nodes have been shown to pose a greater risk of local recurrence while enlarged obturator nodes are a marker for advanced diseases that are more likely to metastasize [85,88], they may be difficult to distinguish from each other and are both removed with a formal lateral pelvic lymph node dissection. However, involvement of external iliac nodes is predictive for metastatic but not local recurrence [89]. These patients do not benefit from lateral pelvic lymph node dissection and might need induction chemotherapy to address systemic disease.

The techniques of a minimally invasive lateral pelvic lymph node dissection for rectal cancer are described in this reference [90].

Anastomosis — Provided that a negative distal margin can be achieved, an important goal of rectal cancer surgery is to spare the anal sphincter, which preserves continence (figure 18) and permits reestablishment of bowel continuity [91]. Patients with poor preexisting anorectal function, however, should be treated with APR and a permanent colostomy rather than with aggressive sphincter-preserving surgery. (See "Abdominal perineal resection (APR): Open technique".)

During LAR, gastrointestinal continuity is usually reestablished by a colorectal or coloanal anastomosis. Those undergoing a colorectal anastomosis typically have sufficient rectal reserve. Patients undergoing coloanal anastomosis, however, often complain of frequent or fragmented stool pattern for at least one year postoperatively. (See "Low anterior resection syndrome (LARS)".)

Several techniques of coloanal anastomosis have been developed to improve their postsurgical bowel function, including colonic J-pouch reservoir, side-to-end (Baker) anastomosis, and transverse coloplasty, to augment the residual reservoir after proctectomy and potentially improve postoperative function. Overall, meta-analyses have not demonstrated substantially different outcomes among these options [92-94].

●Colonic J-pouch – The distal 8 cm of the colon is used to create a pouch in the shape of the letter "J" (figure 19) to provide a larger neorectal reservoir compared with the straight coloanal anastomosis [95-100]. Compared with a straight coloanal anastomosis, a colonic J-pouch procedure does not carry any higher surgical mortality or morbidity (eg, anastomotic leak or stricture, bleeding, reoperations) [92,93,101-105]. For the first year after surgery, most studies associate a colonic J-pouch with better functional outcomes than a straight coloanal anastomosis, but the advantage disappears at two years due to bowel function adaptation [92,93,106]. However, a trial failed to show benefit for a J-pouch over a straight coloanal anastomosis [107].

●Side-to-end (Baker) anastomosis – A side-to-end coloanal anastomosis can be used to increase the neorectal capacity. After resection of the rectum, the side, rather than the end, of the colon is anastomosed to the anal canal, making a "T"-shaped coloanal anastomosis (figure 20). A side-to-end coloanal anastomosis requires fewer staple lines than the colonic J-pouch procedure. Studies comparing a colonic J-pouch to side-to-end anastomosis showed similar outcomes [108,109].

●Transverse coloplasty – Transverse coloplasty makes an 8 to 10 cm longitudinal colotomy between the taeniae coli beginning approximately 4 to 6 cm proximal to the distal end of the mobilized descending colon and reapproximating the incision transversely [93]. The distal end of the colon is anastomosed to the anal sphincter (coloanal anastomosis). Because of its mixed functional results, transverse coloplasty is mostly of historic interest and is rarely performed [93,108,110-115].

Temporary diverting stoma — We suggest constructing a temporary diverting stoma to protect an anastomosis that is low (<5 cm) and/or if the patient has had preoperative pelvic radiation or is on immunosuppressive therapy such as glucocorticoids. In a meta-analysis, patients with a low rectal anastomosis (variably defined as within 5 to 8 cm of the anal verge), male sex, or preoperative radiotherapy benefited the most from temporary fecal diversion [116].

For temporary diversion, loop ileostomy is generally preferred over loop colostomy for ease of reversal; however, loop ileostomy is associated with a higher incidence of high stoma output and dehydration [117]. (See "Overview of surgical ostomy for fecal diversion".)

Several meta-analyses suggested that a defunctioning stoma reduced the rates of both clinically relevant anastomotic leakages and reoperations [118-121]. From a practical standpoint, the complications related to a temporary diverting stoma can be common but manageable, whereas the consequences of an undiverted leak can be catastrophic.

Intersphincteric resection for low rectal cancer — For select patients with low-lying rectal cancer in whom a standard LAR would not yield an adequate distal margin, proctectomy with intersphincteric resection (ISR) may be a viable alternative to APR. ISR extends the distal margin by separating the internal and external anal sphincters and removing the internal sphincter partially or completely [122,123]. Anatomically, the internal anal sphincter is the continuation of the muscular layer of the rectum.

ISR is indicated for lesions <1 cm from the anorectal ring or lesions invading the internal sphincter but not the intersphincteric plane or the external sphincter, as determined by preoperative imaging [122]. The choice between a partial, subtotal, or total ISR depends on the inferior edge of the tumor. Ideal candidates are younger patients with strong presurgery sphincter strength and bowel function.

In a systematic review of 14 retrospective studies including 1289 patients, a margin-negative resection was achieved with ISR in 97.0 percent of patients [124]. The operative mortality and morbidity rates were 0.8 and 25.8 percent. After a median follow-up of 56 (range 1 to 227) months, the mean local recurrence rate was 6.7 (range 0 to 23) percent, and the overall and disease-free survival rates were 86.3 and 78.6 percent, respectively.

Although there are no randomized trials, another meta-analysis of 12 retrospective studies associated ISR with shorter hospital stays, lower postoperative morbidity, and similar oncologic outcomes compared with APR for low rectal cancer [125].

Following a proctectomy with total mesorectal excision (TME) and ISR, intestinal continuity is restored with a coloanal anastomosis. The external anal sphincter is preserved during ISR to ensure reasonable functional outcomes (ie, continence) after surgery [126].

Despite that, patients who undergo ISR generally have worse continence than those who undergo conventional proctectomy with TME [127-129], and a greater proportion of ISR patients develop low anterior resection syndrome [130]. For patients who undergo ISR, fecal urgency was present in up to 58.8 percent of patients [126]; the mean number of bowel movements in a 24 hour period was 2.7 [124]. At 10 years after ISR, about 18 percent of patients required a stoma [131].

SURGICAL APPROACHES — Transabdominal rectal cancer surgery can be performed using open, laparoscopic, or robotic approaches. The choice is determined by surgeon and patient preference as one approach has not been shown to be superior to the others.

In general, minimally invasive rectal cancer surgery should only be performed by surgeons experienced in performing minimally invasive proctectomy with total mesorectal excision (TME). Patients with a threatened or high-risk circumferential margin based on preoperative staging, or with acute bowel obstruction or perforation from rectal cancer, should undergo open rather than minimally invasive surgery. These recommendations are consistent with National Comprehensive Cancer Network (NCCN) guidelines [132].

Laparoscopic versus open — Laparoscopic rectal cancer surgery has been compared with open surgery in five randomized trials with conflicting results:

●Three earlier trials (COLOR II [133,134], CLASICC [135-137], and COREAN [138,139]) reported similar three-year local recurrence rates and five-year disease-free survival rates between the open and laparoscopic groups, although the circumferential radial margin (CRM) positivity rate was slightly higher for the laparoscopic group in the CLASICC trial (16 versus 14 percent) [135].

●Two later trials (ACOSOG Z6051 [140,141], AlaCaRT [142,143]), which examined composite pathologic end points (CRM >1 mm, negative distal margin, and TME completeness), failed to demonstrate noninferiority of laparoscopy compared with open surgery. Although two-year recurrence rates and disease-free survival rates were not different between laparoscopic and open groups, the event rates were low at two years, and longer follow-up data are required to be conclusive.

A systematic review and meta-analysis of 14 randomized trials, including the five described above, concluded that laparoscopic surgery for rectal cancer resulted in a higher rate of "noncomplete" (composite of incomplete and near-complete) TME than open surgery (13.2 versus 10.4 percent), but the two techniques yielded similar rates of circumferential and distal margin involvement, mean numbers of lymph nodes retrieved, and mean distances to radial and distal margins [144]. Another meta-analysis of 12 randomized trials found no significant difference in the rate of overall survival, disease-free survival, locoregional recurrence, or distant recurrence between laparoscopic and open rectal cancer surgery [145].

Laparoscopic rectal cancer surgery has been associated with short-term benefits of less postoperative ileus and pain, a shorter length of stay, fewer postoperative complications, and less blood transfusion. However, most studies were conducted before the practice of enhanced recovery after surgery (ERAS) became widely accepted. It remains to be seen if laparoscopic surgery will still convey the same advantages over open surgery after ERAS protocols have been implemented (see "Enhanced recovery after colorectal surgery"). Other studies found an increased risk of developing sexual dysfunction in men (but not women) after laparoscopic rectal cancer surgery compared with open surgery [146-148].

Robotic versus laparoscopic — Robot-assisted surgical procedures are an emerging technology that combines the advantages of the laparoscopic approach (eg, less postoperative pain, faster recovery) with the advantages of the open approach (eg, high-quality three-dimensional vision, restoration of the eye-hand-target axis) [149-152].

The RObotic versus LAparoscopic Resection of Rectal Cancer Trial (ROLARR) trial compared the short-term (six-month) outcomes of 466 patients who underwent low anterior resection or abdominoperineal resection for rectal cancer [153]. Robotic-assisted and conventional laparoscopic surgery resulted in statistically similar rates of conversion to laparotomy (8.1 versus 12.2 percent), positive circumferential resection margin (5.1 versus 6.3 percent), mortality (0.9 versus 0.9 percent), overall complications (33.1 versus 31.7 percent), intraoperative complications (15.3 versus 14.8 percent), anastomotic leak (12.2 versus 9.9 percent), and postoperative bladder or sexual dysfunction. The robotic approach was associated with a longer operative time (by an average of 38 minutes) and a higher hospital cost (by an average of 980 pounds or 1132 dollars per patient).

A 2018 systematic review and meta-analysis of five trials comparing robotic-assisted versus conventional laparoscopic resection for rectal cancer, including ROLARR, found similar perioperative outcomes such as mortality, rate of circumferential margin involvement, and number of lymph nodes harvested [154]. Robotic surgery was less likely to convert to open surgery (7.5 versus 12.9 percent) but took slightly longer than conventional laparoscopic surgery (mean difference 38 minutes).

A 2022 systematic review and meta-analysis of 2 trials and 12 observational studies found that robotic rectal cancer resection was associated with fewer male sexual and urinary dysfunctions when compared with laparoscopy, but there was no difference in quality of life or gastrointestinal function [155]. However, data on patient-related functional outcomes are limited because the studies either do not report all facets of functional outcomes or do not use the same assessment tools.

One study reported that the use of robotic proctectomy increased from 3.1 to 26.7 percent from 2012 to 2018 according to data from the Michigan Surgical Quality Collaborative [156]. However, one should also keep in mind that the published prospective data addressing the issue of oncologic equivalency of robotic-assisted laparoscopic surgery to either conventional laparoscopic or open rectal surgery are limited. In a report from the MD Anderson Cancer Center, there was a high rate of successful rectal cancer resection following a robotic approach, and the short- and medium-term oncologic outcomes were good [157].

The techniques of laparoscopic/robotic rectal surgery are discussed in another topic. (See "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy", section on 'Laparoscopic/robotic proctectomy'.)

SPECIAL CONSIDERATIONS DURING THE COVID-19 PANDEMIC — The COVID-19 pandemic has increased the complexity of cancer care. Important issues include balancing the risk from delaying cancer treatment versus harm from COVID-19, minimizing the number of clinic and hospital visits to reduce exposure whenever possible, mitigating the negative impacts of social distancing on delivery of care, and appropriately and fairly allocating limited healthcare resources. Specific guidance for decision-making for cancer surgery on a disease-by-disease basis is available from the American College of Surgeons, from the Society for Surgical Oncology, and from others. These and other recommendations for cancer care during active phases of the COVID-19 pandemic are discussed separately. (See "COVID-19: Considerations in patients with cancer".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colorectal cancer" and "Society guideline links: Colorectal surgery for cancer".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Colon and rectal cancer (The Basics)")

●Beyond the Basics topics (see "Patient education: Colon and rectal cancer (Beyond the Basics)" and "Patient education: Colorectal cancer treatment; metastatic cancer (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Principles of radical resection of rectal cancer – Surgery is the cornerstone of curative therapy for patients with resectable rectal cancer. All transabdominal surgical resection of the rectum must achieve all of the following (see 'Principles of radical resection' above):

•Total mesorectal excision – For patients undergoing either a low anterior resection (LAR) or an abdominoperineal resection (APR) of a rectal cancer, we recommend performing a total mesorectal excision (TME) rather than a blunt dissection (Grade 1B).

A TME should be performed to a level of 5 cm below the distal margin of the primary tumor for tumors in the upper rectum or to the pelvic floor (complete TME) for tumors in the lower or middle rectum. (See 'Total mesorectal excision' above.)

•Negative distal margin – Intraoperatively, the minimum acceptable negative distal margin is 2 cm for cancers located above the distal mesorectal margin. For cancers located at or below the distal mesorectal margin, a 1 cm negative distal margin is acceptable. Margins of resection must be histologically negative on the final pathology report. Intersphincteric resection may help extend the distal margin by removing the internal sphincter muscle in suitable candidates. Failure to achieve an adequate distal margin mandates conversion of an LAR to an APR. (See 'Distal margin' above and 'Intersphincteric resection for low rectal cancer' above.)

•Negative proximal margin – A minimum negative proximal margin of 5 cm is required. (See 'Proximal margin' above.)

•Negative circumferential radial margins – A circumferential radial margin of greater than 1 mm is required. (See 'Radial margins' above.)

•Vascular ligation and lymph node dissection – In most patients with rectal cancer, a lymph node dissection up to the level of the origin of the superior rectal artery should be performed (figure 14). "High" ligation of the inferior mesenteric artery at the origin of the aorta (figure 12), or extended lymph node dissection laterally, is not necessary in the absence of clinically positive nodes. A benchmark of 12 lymph nodes has been adopted as a quality metric for colorectal cancer surgery by several societies, although the number of lymph nodes recovered may be lower after neoadjuvant chemoradiation therapy. Persistently enlarged lymph nodes after neoadjuvant therapy in a lateral compartment may trigger lymphadenectomy of that compartment, although the practice varies by geographic location. (See 'Vascular ligation' above and 'Lymph node dissection' above.)

●Anastomotic techniques – Sphincter-sparing procedures such as LAR restore intestinal continuity with a colorectal or coloanal anastomosis. Colorectal anastomosis usually assures sufficient rectal capacity; coloanal anastomosis may be augmented by colonic J-pouch reservoir, side-to-end (Baker) anastomosis, or transverse coloplasty, but none has shown long-term benefit over a straight coloanal anastomosis. A temporary diverting stoma should be constructed to protect an anastomosis that is low (<5 cm) and/or if the patient has had preoperative pelvic radiation or is on immunosuppressive therapy such as glucocorticoids. (See 'Anastomosis' above and 'Temporary diverting stoma' above.)

●Surgical approaches – Transabdominal rectal cancer surgery can be performed via open, laparoscopic, or robotic approaches. The best surgical approach needs to be determined individually by tumor and patient characteristics, as well as surgeon experience; one approach has not been shown to be superior to the others. (See 'Surgical approaches' above.)

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  137. Jayne DG, Thorpe HC, Copeland J, et al. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 2010; 97:1638.
  138. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11:637.
  139. Jeong SY, Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014; 15:767.
  140. Fleshman J, Branda M, Sargent DJ, 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; 314:1346.
  141. Fleshman J, Branda ME, Sargent DJ, et al. Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial. Ann Surg 2019; 269:589.
  142. Stevenson AR, Solomon MJ, Lumley JW, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA 2015; 314:1356.
  143. Stevenson ARL, Solomon MJ, Brown CSB, et al. Disease-free Survival and Local Recurrence After Laparoscopic-assisted Resection or Open Resection for Rectal Cancer: The Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial. Ann Surg 2019; 269:596.
  144. Martínez-Pérez A, Carra MC, Brunetti F, de'Angelis N. Pathologic Outcomes of Laparoscopic vs Open Mesorectal Excision for Rectal Cancer: A Systematic Review and Meta-analysis. JAMA Surg 2017; 152:e165665.
  145. Creavin B, Kelly ME, Ryan ÉJ, et al. Oncological outcomes of laparoscopic versus open rectal cancer resections: meta-analysis of randomized clinical trials. Br J Surg 2021; 108:469.
  146. Andersson J, Abis G, Gellerstedt M, et al. Patient-reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II). Br J Surg 2014; 101:1272.
  147. Quah HM, Jayne DG, Eu KW, Seow-Choen F. Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for cancer. Br J Surg 2002; 89:1551.
  148. Jayne DG, Brown JM, Thorpe H, et al. Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg 2005; 92:1124.
  149. Collinson FJ, Jayne DG, Pigazzi A, et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis 2012; 27:233.
  150. Ayav A, Bresler L, Hubert J, et al. Robotic-assisted pelvic organ prolapse surgery. Surg Endosc 2005; 19:1200.
  151. Munz Y, Moorthy K, Kudchadkar R, et al. Robotic assisted rectopexy. Am J Surg 2004; 187:88.
  152. Heemskerk J, Zandbergen R, Maessen JG, et al. Advantages of advanced laparoscopic systems. Surg Endosc 2006; 20:730.
  153. Jayne D, Pigazzi A, Marshall H, et al. Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial. JAMA 2017; 318:1569.
  154. Prete FP, Pezzolla A, Prete F, et al. Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2018; 267:1034.
  155. Flynn J, Larach JT, Kong JCH, et al. Patient-Related Functional Outcomes After Robotic-Assisted Rectal Surgery Compared With a Laparoscopic Approach: A Systematic Review and Meta-analysis. Dis Colon Rectum 2022; 65:1191.
  156. Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open 2020; 3:e1918911.
  157. Sammour T, Malakorn S, Bednarski BK, et al. Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database. Ann Surg 2018; 267:521.
Topic 17127 Version 36.0

References

1 : Wexner SD, Jorge JMN. Chapter 1. Anatomy and embryology of the anus, rectum, and colon. In: Colon & Rectal Surgery, 5th ed, Corman ML (Ed), Lippincott Williams & Wilkins, Philadelphia 2005. p.1.

2 : Practice parameters for the management of rectal cancer (revised).

3 : Definition of the Rectum: An International, Expert-based Delphi Consensus.

4 : Consensus statement of definitions for anorectal physiology and rectal cancer.

5 : The valves of Houston in adults.

6 : Definition of the rectum and level of the peritoneal reflection - still a matter of debate?

7 : Anatomical lymph node mapping in normal mesorectal adipose tissue.

8 : Endoscopic lymphoscintigraphy. A new tool for target surgery of rectal cancer.

9 : Understanding the anatomy of lymphatic drainage and the use of blue-dye mapping to determine the extent of lymphadenectomy in rectal cancer surgery: unresolved issues.

10 : American College of Surgeons Commission on Cancer Standard 5.7 for Total Mesorectal Excision for Mid-to-Low Rectal Cancer.

11 : Total mesorectal excision and local recurrence: a study of tumour spread in the mesorectum distal to rectal cancer.

12 : Lymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total mesorectal excision.

13 : Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection.

14 : Guidelines 2000 for colon and rectal cancer surgery.

15 : Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial.

16 : The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results.

17 : Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.

18 : A national strategic change in treatment policy for rectal cancer--implementation of total mesorectal excision as routine treatment in Norway. A national audit.

19 : Development of quality indicators for patients undergoing colorectal cancer surgery.

20 : Effective surgical adjuvant therapy for high-risk rectal carcinoma.

21 : Mesorectal excision for rectal cancer.

22 : Ultra-low anterior resection and coloanal pouch reconstruction for carcinoma of the distal rectum.

23 : Total mesorectal excision for surgical treatment of rectal cancer.

24 : Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial.

25 : Autonomic nerve preservation in rectal cancer surgery --the forgotten part of the TME message a practical "workshop" description for surgeons.

26 : Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence.

27 : A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy.

28 : Transanal Total Mesorectal Excision: International Registry Results of the First 720 Cases.

29 : Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer (Ta-LaTME study): multicentre, randomized, open-label trial.

30 : Trans-anal or trans-abdominal total mesorectal excision? A systematic review and meta-analysis of recent comparative studies on perioperative outcomes and pathological result.

31 : Short-term Outcomes of Transanal versus Laparoscopic Total Mesorectal Excision: A Systematic Review and Meta-Analysis of Cohort Studies.

32 : Short- and long-term outcomes of transanal versus laparoscopic total mesorectal excision for mid-to-low rectal cancer: a meta-analysis.

33 : Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study.

34 : Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries.

35 : Transanal total mesorectal excision and low anterior resection syndrome.

36 : Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: short- and mid-term results.

37 : Transanal Total Mesorectal Excision: Short-term Outcomes of 1283 Cases from a Nationwide Registry in China.

38 : Association of Transanal Total Mesorectal Excision With Local Recurrence of Rectal Cancer.

39 : Norwegian moratorium on transanal total mesorectal excision.

40 : The ACPGBI recommends pause for reflection on transanal total mesorectal excision.

41 : Local Recurrence and Disease-Free Survival After Transanal Total Mesorectal Excision: Results From the International TaTME Registry.

42 : Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve.

43 : Learning Curve for Transanal Total Mesorectal Excision for Low Rectal Malignancy.

44 : Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve.

45 : The learning curve of TaTME for mid-low rectal cancer: a comprehensive analysis from a five-year institutional experience.

46 : Tumor size and regional lymph node metastasis in colorectal cancer. A preliminary analysis from the NSABP clinical trials.

47 : An analysis of survival and treatment failure following abdominoperineal and sphincter-saving resection in Dukes' B and C rectal carcinoma. A report of the NSABP clinical trials. National Surgical Adjuvant Breast and Bowel Project.

48 : Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis.

49 : Is the 1-cm rule of distal bowel resection margin in rectal cancer based on clinical evidence? A systematic review.

50 : Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are<or = 1 cm distal margins sufficient?

51 : What is the role for the circumferential margin in the modern treatment of rectal cancer?

52 : Circumferential margin involvement is the crucial prognostic factor after multimodality treatment in patients with locally advanced rectal carcinoma.

53 : Role of circumferential margin involvement in the local recurrence of rectal cancer.

54 : A circumferential resection margin of 1 mm is a negative prognostic factor in rectal cancer patients with and without neoadjuvant chemoradiotherapy.

55 : Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision.

56 : High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action.

57 : Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study.

58 : Embryological Development and Topographic Anatomy of Pelvic Compartments-Surgical Relevance for Pelvic Lymphonodectomy.

59 : The middle rectal artery detected by contrast-enhanced magnetic resonance imaging predicts lateral lymph node metastasis in lower rectal cancer.

60 : Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery.

61 : Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection for Rectal Cancer Reduces Genitourinary Dysfunction: Results From a Randomized Controlled Trial (HIGHLOW Trial).

62 : High tie versus low tie in rectal surgery: comparison of anastomotic perfusion.

63 : Preservation versus non-preservation of left colic artery in sigmoid and rectal cancer surgery: A meta-analysis.

64 : High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis.

65 : High tie versus low tie of the inferior mesenteric artery in colorectal cancer: A meta-analysis.

66 : Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery.

67 : A US Rectal Cancer Consortium Study of Inferior Mesenteric Artery Versus Superior Rectal Artery Ligation: How High Do We Need to Go?

68 : Meeting the 12 lymph node (LN) benchmark in colon cancer.

69 : Prognostic factors in colorectal cancer. College of American Pathologists Consensus Statement 1999.

70 : Impact of number of nodes retrieved on outcome in patients with rectal cancer.

71 : Fewer than 12 lymph nodes can be expected in a surgical specimen after high-dose chemoradiation therapy for rectal cancer.

72 : Lymph node yield in rectal cancer surgery: effect of preoperative chemoradiotherapy.

73 : Challenging the feasibility and clinical significance of current guidelines on lymph node examination in rectal cancer in the era of neoadjuvant therapy.

74 : The effects of preoperative chemoradiotherapy on lymph node sampling in rectal cancer.

75 : Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think!

76 : Anatomy of the middle rectal artery: a review of the historical literature.

77 : Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for treatment of colorectal cancer.

78 : Mesorectal Excision With or Without Lateral Lymph Node Dissection for Clinical Stage II/III Lower Rectal Cancer (JCOG0212): A Multicenter, Randomized Controlled, Noninferiority Trial.

79 : Long-term follow-up of the randomized trial of mesorectal excision with or without lateral lymph node dissection in rectal cancer (JCOG0212).

80 : Meta-analysis of survival and functional outcomes after total mesorectal excision with or without lateral pelvic lymph node dissection in rectal cancer surgery.

81 : Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer.

82 : Patterns of local recurrence in rectal cancer; a study of the Dutch TME trial.

83 : Rectal cancer lateral pelvic sidewall lymph nodes: a review of controversies and management.

84 : Optimal Size Criteria for Lateral Lymph Node Dissection After Neoadjuvant Chemoradiotherapy for Rectal Cancer.

85 : Lateral Nodal Features on Restaging Magnetic Resonance Imaging Associated With Lateral Local Recurrence in Low Rectal Cancer After Neoadjuvant Chemoradiotherapy or Radiotherapy.

86 : Who Should Get Lateral Pelvic Lymph Node Dissection After Neoadjuvant Chemoradiation?

87 : Magnetic Resonance Imaging Directed Surgical Decision Making for Lateral Pelvic Lymph Node Dissection in Rectal Cancer After Total Neoadjuvant Therapy (TNT).

88 : Rectal cancer lateral lymph nodes: multicentre study of the impact of obturator and internal iliac nodes on oncological outcomes.

89 : Survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved.

90 : Lateral Node Dissection in Rectal Cancer in the Era of Minimally Invasive Surgery: A Step-by-Step Description for the Surgeon Unacquainted with This Complex Procedure with the Use of the Laparoscopic Approach.

91 : Rectal cancer.

92 : Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer.

93 : Reconstructive techniques after rectal resection for rectal cancer.

94 : Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis.

95 : Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum.

96 : Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma.

97 : Prediction of optimum dimensions of colonic pouch reservoir.

98 : Reconstruction techniques after proctectomy: what's the best?

99 : Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis.

100 : Pouch operation for rectal cancer.

101 : Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial.

102 : Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial.

103 : Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection.

104 : Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch: is the functional superiority of colonic J-pouch sustained?

105 : Morbidity Following Coloanal Anastomosis: A Comparison of Colonic J-Pouch vs Straight Anastomosis.

106 : Better Function With a Colonic J-Pouch or a Side-to-end Anastomosis?: A Randomized Controlled Trial to Compare the Complications, Functional Outcome, and Quality of Life in Patients With Low Rectal Cancer After a J-Pouch or a Side-to-end Anastomosis.

107 : Colonic J-Pouch or Straight Colorectal Reconstruction After Low Anterior Resection For Rectal Cancer: Impact on Quality of Life and Bowel Function: A Multicenter Prospective Randomized Study.

108 : A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.

109 : J-pouch vs. side-to-end anastomosis after hand-assisted laparoscopic low anterior resection for rectal cancer: A prospective randomized trial on short and long term outcomes including life quality and functional results.

110 : Reasons for failure to construct the colonic J-pouch. What can be done to improve the size of the neorectal reservoir should it occur?

111 : Coloplasty in low colorectal anastomosis: manometric and functional comparison with straight and colonic J-pouch anastomosis.

112 : Transverse coloplasty pouch after total mesorectal excision: functional assessment of evacuation.

113 : Colonic J-pouch vs. coloplasty following resection of distal rectal cancer: early results of a prospective, randomized, pilot study.

114 : Transverse coloplasty pouch and colonic J-pouch for rectal cancer--a comparative study.

115 : Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates.

116 : Preoperative risk factors for anastomotic leakage after resection for colorectal cancer: a systematic review and meta-analysis.

117 : The Role of Temporary Fecal Diversion.

118 : Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery.

119 : Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer.

120 : Covering ileo- or colostomy in anterior resection for rectal carcinoma.

121 : Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis.

122 : Low rectal cancer: classification and standardization of surgery.

123 : Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience.

124 : Systematic review of outcomes after intersphincteric resection for low rectal cancer.

125 : Records of Cucullanus truttae (Fabricius, 1794) (Nematoda: Cucullanidae) from Swedish brook lampreys, Lampetra planeri (Bloch).

126 : Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer.

127 : Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study.

128 : Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer.

129 : Long-term clinical and functional results of intersphincteric resection for lower rectal cancer.

130 : Outcome of bowel function following anterior resection for rectal cancer-an analysis using the low anterior resection syndrome (LARS) score.

131 : The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer.

132 : The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer.

133 : Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial.

134 : A randomized trial of laparoscopic versus open surgery for rectal cancer.

135 : Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial.

136 : Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group.

137 : Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer.

138 : Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial.

139 : Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial.

140 : Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial.

141 : Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial.

142 : Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial.

143 : Disease-free Survival and Local Recurrence After Laparoscopic-assisted Resection or Open Resection for Rectal Cancer: The Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial.

144 : Pathologic Outcomes of Laparoscopic vs Open Mesorectal Excision for Rectal Cancer: A Systematic Review and Meta-analysis.

145 : Oncological outcomes of laparoscopic versus open rectal cancer resections: meta-analysis of randomized clinical trials.

146 : Patient-reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II).

147 : Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for cancer.

148 : Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique.

149 : An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer.

150 : Robotic-assisted pelvic organ prolapse surgery.

151 : Robotic assisted rectopexy.

152 : Advantages of advanced laparoscopic systems.

153 : Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial.

154 : Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

155 : Patient-Related Functional Outcomes After Robotic-Assisted Rectal Surgery Compared With a Laparoscopic Approach: A Systematic Review and Meta-analysis.

156 : Trends in the Adoption of Robotic Surgery for Common Surgical Procedures.

157 : Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database.

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