Q: How do you determine which operation you use for a patient with rectal cancer?
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A: I think the most important thing to understand about rectal cancer is that they are unique to the individual patient.
There are a lot of different factors that go into how we handle a tumor, such as the height of the tumor (where it is in the rectum), how advanced it is (through the wall of the rectum or growing into other organs or nodes), the body habitus of the patient in many cases, and even gender differences.
We have various surgical approaches to the rectum, both open and minimally invasive. While the goal is always to take the cancer out and connect the patient back up, we want to make sure our first and foremost priority is to do a great oncological resection (removing all the cancer following standard principles). Then, if we can, we want to preserve the patient’s continuity — but that’s always the secondary factor. Having the best oncological result always come first.
For example, with a big tumor that extends a little bit lower, wider or more locally advanced, sometimes an extended APR (or ELAPE), removing extra tissue and levator muscle outside of sphincters, is the right operation. But otherwise, a standard abdominoperineal resection (APR) that meets all the principles of a standard cancer operation maybe the right option for that individual patient.
There are many techniques, ranging from transanal TME and laparoscopy to robotic or even open surgery — all depending on the patient and the surgeon’s experience — and each may be the right procedure for that patient and that tumor. But at the end of the day, the principles of the operation, despite the surgical approach, stay the same.
— Scott R.Steele, MD
Chairman, Colorectal Surgery