Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences

HYPOTHESIS: Total mesorectal excision lowers the rate of pelvic recurrence and positively affects the survival after surgical treatment of rectal cancer. DESIGN: Case series. SETTING: Tertiary care university hospital. PATIENTS: Fifty-three consecutive patients were admitted with curative intent to surgery at the First Department of Surgery of the University of Rome "La Sapienza," Rome, Italy, with diagnoses of rectal carcinoma. The mean follow-up was 68.9 months; follow-up was complete for all patients who entered the trial. INTERVENTIONS: Low anterior resection and total mesorectal excision were performed in all cases, regardless of the location of the rectal cancer. A straight mechanical colorectal anastomosis was performed on a rectal stump, never exceeding 5 cm. No kind of adjuvant therapy was given. Mesorectum and open rectum were studied by serial transverse section at 5-mm intervals. A search for depth of penetration and distal intramural extension of the tumor was made. Lymph nodes were detected by clearing method, and nodal metastases (NM) and nonnodal metastases (NNM) were recorded as situated proximally, distally, or at the level of the tumor. RESULTS: There was no postoperative mortality. Clinical and radiologic leaks occurred in 2 and 4 patients, respectively. Mean disease-free survival was 65.9 months. Pelvic recurrence occurred in 5 patients (9%). Overall 5-year survival rate was 75%. Involvement of mesorectum by NM and NNM was detected in 27 and 24 cases, respectively. Both NM and NNM were found to be distal in 33% and 40% of cases, respectively. CONCLUSIONS: Microscopic spread to the distal mesorectum may exceed the intramural spread of rectal cancer. Failure to perform total mesorectal excision leaves a potentially residual disease in the distal mesorectum, thus predisposing the patient to pelvic recurrence.     

Distal dissection in total mesorectal excision,and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4–5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.     

Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.     

Resection of rectal cancer: A historical review

Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques and adjuvant therapy. By applying advanced surgical principles, surgeons can now excise most rectal cancers completely, often preserving the anal sphincter and leaving the patient with relatively normal bowel and pelvic function. Historically, the earliest surgical approaches to rectal cancer were via the perineum. As surgical techniques and general anesthesia improved, other approaches such as a posterior approach were undertaken to improve access to the whole rectum. Consequently, abdominoperineal resection became the standard treatment until anterior resection was introduced for proximal rectal cancers. The most important surgical breakthrough in recent years has been the advent of total mesorectal excision (TME). The emphasis in rectal cancer surgery is on preservation of function, with dissection being done in appropriate anatomical planes. Thus, mobilization of the rectum has a long history, and is seen in modern procedures including TME and intersphincter resection. This article reviews the progression of the surgical management of rectal cancer with reference to historical perspectives. We discuss the major surgical considerations for mobilization of the rectum in several surgical procedures, from conventional operations to modern standardized TME.     

Mesorectal lymph node dissection: is it beneficial?

Locoregional recurrences and distant metastases are the determinants of the long-term prognosis following curative resection of rectal carcinoma. While distant metastases cannot be affected by the surgical treatment of the primary tumor, avoidance of local recurrence by the surgeon is of special significance as the predominant prognostic factor. Analysis of the long-term results achieved by various surgeons led to the concept of mesorectal excision – the removal of the rectum together with all additional tissue invested by the adjacent visceral fascia, that is, fatty tissue, lymph nodes, and lymphatic vessels, by sharp dissection of the appropriate anatomical plane. In our own patient material the 5-year survival rate following R0 resection was 85% for all stages, provided no local recurrence developed. This contrasts with a figure of only 23% in those who did develop local recurrence. The local recurrence rate decreased from 39.4%, with a 50% 5-year survival rate in 1974, to 9.8% and a 71% survival rate in 1991, although the rate of distant metastases remained constant. Among the patients treated between 1988 and 1994 the local recurrence rate was determined by depth of infiltration (1987 UICC classification: pT1 0%, pT2 10%, pT3 14%, pT4 28%), extent of lymph node infiltration (pN0 6%, pN1 15%, pN2 26%, pN3 25%), grading (G1 9%, G2 12%, G3 21%), and location within the rectum (upper third 13%, middle third 8%, lower third 17%), with combinations of unfavorable initial factors leading to higher local recurrence rates. The elevated local recurrence rates seen in the 1970s, in particular in the case of tumors of the lower third, were traced retrospectively to incomplete mesorectal excision, the implementation of which reduced the local recurrence rate initially to less than 10%, and then to the current 4.1%. From the oncological point of view, mesorectal excision must be considered to confer considerable benefit. In the case of carcinomas of the upper third of the rectum, mesorectal resection carried out to just 5 cm below the lower tumor edge is sufficient, however, without coning, while deeper carcinomas mandate total mesorectal excision. Received: 21 October 1998 / Accepted: 26 October 1998     

Strategies in the management of mid and distal rectal cancer with total mesorectal excision

In the last two decades, dramatic improvement in outcome has been made in the management of rectal cancer. This has been brought about mainly by advancements in surgical technique for radical resection. With the recognition of the importance of the circumferential margin and presence of spread in the lymphovascular tissues in the mesorectum, total mesorectal excision is now commonly recognized as the optimal surgical technique for cancer of the mid and distal rectum. Not only have local control and disease-specific survival improved with the practice of total mesorectal excision, but various bodily functions have also been preserved following surgery for rectal cancer. New issues have arisen with the practice of total mesorectal excision and the strategies for management of rectal cancer require re-evaluation. In this article, the rationale and the outcomes of total mesorectal excision are reviewed. Issues such as the high anastomotic leakage rate following sphincter-preserving surgery, the poor results of abdominoperineal resection, the role of adjuvant therapy and bowel function disturbances will be addressed. Lastly, the status of the laparoscopic approach to rectal cancer with the principle of total mesorectal excision are discussed.     

Photodynamic therapy with motexafin lutetium for rectal cancer: a preclinical model in the dog

PURPOSE: Local recurrence of rectal cancer remains a significant clinical problem despite multi-modality therapy. Photodynamic Therapy (PDT) is a cancer treatment which generates tumor kill through the production of singlet oxygen in cells containing a photosensitizing drug when exposed to laser light of a specific wavelength. PDT is a promising modality for prevention of local recurrence of rectal cancer for several reasons: tumor cells may selectively retain photosensitizer at higher levels than normal tissues, the pelvis after mesorectal excision is a fixed space amenable to intra-operative illumination, and PDT can generate toxicity in tissues up to 1 cm thick. This study evaluated the safety, tissue penetration of 730 nm light, normal tissue toxicity and surgical outcome in a dog model of rectal resection after motexafin lutetium-mediated photodynamic therapy. METHODS: Ten mixed breed dogs were used. Eight dogs underwent proctectomy and low rectal end to end stapled anastomosis. Six dogs received the photosensitizing agent motexafin lutetium (MLu, Pharmacyclics, Inc., Sunnyvale, CA) of 2 mg/kg preoperatively and underwent subsequent pelvic illumination of the transected distal rectum of 730 nm light with light doses ranging from 0.5 J/cm(2) to 10 J/cm(2) three hours after drug delivery. Two dogs received light, but no drug, and underwent proctectomy and low-rectal stapled anastomosis. Two dogs underwent midline laparotomy and pelvic illumination. Light penetration in tissues was determined for small bowel, rectum, pelvic sidewall, and skin. Clinical outcomes were recorded. Animals were sacrificed at 14 days and histological evaluation was performed. RESULTS: All dogs recovered uneventfully. No dog suffered an anastomotic leak. Severe tissue toxicity was not seen. Histological findings at necropsy revealed mild enteritis in all dogs. The excitation light penetration depths were 0.46 +/- 0.18, 0.46 +/- 0.15, and 0.69 +/- 0.39 cm, respectively, for rectum, small bowel, and peritoneum in dogs that had received MLu. For control dogs without photosensitizer MLu, the optical penetration depths were longer: 0.92 +/- 0.63, 0.67 +/- 0.10, and 1.1 +/- 0.80 cm for rectum, small bowel, and peritoneum, respectively. CONCLUSION: Low rectal stapled anastomosis is safe when performed with MLu-mediated pelvic PDT in a dog model. Significant tissue penetration of 730 nm light into the rectum and pelvic sidewall was revealed without generation of significant toxicity or histological sequelae. Penetration depths of 730 nm light in pelvic tissue suggest that microscopic residual disease of less than 5 mm are likely to be treated adequately with MLu-mediated PDT. This approach merits further investigation as an adjuvant to total mesorectal excision and chemoradiation for rectal cancer.     

应用流式细胞技术及病理检测对直肠癌手术切除范围的再探讨

目的探讨直肠癌根治术合理的手术范围。方法应用病理检测和流式细胞技术,对30例直肠癌全直肠系膜切除术标本进行分析,观察直肠癌组织和癌远端3cm和5cm、正常肠管组织和癌旁3cm和5cm直肠系膜及正常结肠系膜组织的DNA倍体、DNA指数（DI）、增殖指数（PI）和增殖期细胞百分比（SPF）值的变化,并与病理检测相对照。结果病理检测结果显示：直肠癌远端3cm和5cm肠管中均未检测到癌浸润．而癌旁3cm和5cm直肠系膜癌转移率分别为26．7％和6．7％。流式细胞技术检测结果显示：癌组织的DI、P1和SPF值显著高于癌远端3cm和5cm及正常肠管组织,癌远端3cm肠管组织也显著高于癌远端5cm及正常肠管组织,而癌远端5cm肠管与正常肠管比较,差异无统计学意义（P〉0．05）。癌组织细胞异倍体率与癌远端3cm肠管比较,差异无统计学意义（P〉0．05）;而显著高于癌远端5cm及正常肠管组织。癌组织的DI和异倍体率与癌旁3cm和5cm直肠系膜组织相比,差异无统计学意义．但显著高于正常系膜,而癌旁3cm和5cm直肠系膜组织的DI和异倍体率亦显著高于正常系膜。癌组织P1和SPF则显著高于癌旁3cm和5cm及正常系膜。结论病理学分析结果显示．直肠癌远端3cm肠管组织为安全组织;而流式细胞学分析结果显示．直肠癌远端3cm肠管组织和癌旁5cm直肠系膜为不安全组织;手术切除范围应达癌远端系膜5cm以上。     

Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N-status matter

Tumour deposits (TDs), novel pathological entities, should be considered when estimating the regional and systemic spread of rectal carcinoma and formulating treatment strategies. In fact, TDs may have more severe prognostic impact than lymph node positivity or the lymph node ratio. The assessment of the presence of TDs can be performed only through accurate postoperative pathological examination; however, the detection of TDs is not part of any of the procedures currently used to assess preoperative or intraoperative staging. This review aims to analyse and discuss the impact of TDs on the oncological outcome of patients who undergo surgery for advanced low rectal carcinoma. No prospective study has evaluated the impact of lateral pelvic TDs on oncological outcomes following total mesorectal excision with lateral pelvic lymphadenectomy. Although adequate total mesorectal excision allows for the excision of intramesorectal TDs, lateral pelvic lymph node dissection cannot guarantee the removal of lateral pelvic TDs; moreover, it remains to be determined whether surgical excision of lateral pelvic TDs can impact long-term outcomes. However, the identification of lateral pelvic TDs strengthens the ‘staging effect’ and limits the ‘therapeutic effect’ of lateral pelvic lymphadenectomy, supporting the rationale for the use of neoadjuvant chemoradiotherapy for rectal cancer. When evaluating the oncological outcomes after total mesorectal excision with lateral pelvic lymphadenectomy, the impact of lateral pelvic TDs should be considered.     

低位直肠癌保功能手术的相关问题

外科手术是治疗直肠癌的基础,尤其是对于低位直肠癌,在追求远期肿瘤学疗效的同时,如何更好地兼顾患者术后生命质量,保留正常生理功能,一直是业界关注的重要问题。近年来,随着对直肠癌病理学与分子病理学理解的深入、多学科综合诊断与治疗策略的优化与发展、全直肠系膜切除术和保留盆腔自主神经等手术技术和治疗理念的引入,以及技术设备与外科手术方式的持续创新,低位直肠癌保功能手术得到不断完善与持续发展。直肠癌外科领域未来的发展方向无疑将更多地体现在功能的保留与保护等方面。对于低位直肠癌患者,在保证肿瘤根治前提下如何最大限度地保留功能,有赖于精准选择以循证医学证据为基础的治疗策略和精细地施行个体化的保肛手术。     

Laparoscopic total mesorectal excision for low rectal cancer

Background

Laparoscopic total mesorectal excision for rectal cancer is coming out of age with recent publications highlighting its safety, feasibility, sound oncological outcomes, and improved quality of life. Nevertheless, laparoscopic proctectomy remains a challenging procedure. An embedded didactic video demonstrates a step-by-step laparoscopic total mesorectal excision with coloanal anastomosis for a low rectal cancer.

Methods

A five-trocar technique is shown. The key steps demonstrated are: high division of the inferior mesenteric artery, medial-to-lateral mobilization of the descending colon, high division of the inferior mesenteric vein, take-down of the splenic flexure, total mesorectal excision with division of the rectum at the pelvic floor, and side-to-end coloanal anastomosis. Principles of a good anastomosis and potential pitfalls are described, including protection of the ureter and pelvic autonomic nerves.

Results

A series of ten consecutive patients operated for low rectal cancer with total mesorectal excision is reported. Median (range) operative time and estimated blood loss were 274 (135?C360) minutes and 25 (10?C50)?ml. Median tumor height from the anal verge was 7 (4?C10)?cm. Reconstruction included three coloanal J-pouch and seven side-to-end anastomosis. Nine anastomoses were performed by using a double-stapled technique. One patient with an intersphincteric dissection required a handsewn anastomosis. A diverting ileostomy protected all coloanal anastomosis. Median length of stay was 3 (range, 2?C7) days. One of ten patients was readmitted for a small bowel obstruction. The embedded video demonstrates a total mesorectal excision down to the pelvic floor in a patient who had a T2 cancer 6?cm from the anal verge with prior open cholecystectomy and hysterectomy.

Conclusions

Laparoscopic total mesorectal excision is a safe and effective procedure. Patient selection and advanced laparoscopic skills are paramount. It is hoped that this didactic video will contribute to a wider and safer practice of laparoscopic total mesorectal excision for low rectal cancer.     

Endoscopic posterior mesorectal resection as an option to combine local treatment of early stage rectal cancer with partial mesorectal lymphadenectomy

Background and aims Low anterior resection and abdominoperineal resection with total mesorectal excision are the standard treatment in patients with low rectal cancer. Rectal resection remains a surgical intervention with considerable morbidity and long-term impairment of quality of life. Local excision of low rectal cancer is regarded as an alternative to radical surgery; however, occurrence of lymph node metastasis even in patients with highly differentiated early-stage rectal cancer may be underestimated. Patients and results In two patients with T1 rectal cancer, minimal-invasive partial excision of the mesorectum was performed after transanal excision of the tumor. The postoperative course was uneventful in both patients. Patients left the hospital on the fourth and fifth postoperative day without any complaints. In one patient, histo-pathological workup revealed a lymph node metastasis in the specimen. Discussion The technique of “Endoscopic posterior mesorectal resection” represents an interesting option in the surgical treatment of rectal cancer, as it allows for the first time an organ preserving resection of local lymph nodes in the small pelvis. It may evolve as an efficient new staging procedure to identify patients with metastatic disease who may benefit from multimodal treatment or extended surgery.     

An assessment of the anatomical relationship between the pelvic plexus and the rectal wall to determine the indications for its preservation in surgery for rectal cancer

Preservation of the pelvic plexus in surgery for rectal cancer could shorten the distance between the cancer and the lateral resection margin, whereby the curability of the operation may be reduced. To clarify the indications for preserving the pelvic plexus in such surgery, the relationship of the pelvic plexus to the rectum and rectal cancer was investigated anatomically in 12 autopsied specimens and 12 surgical specimens. The rectum and anus were dissected with all the pelvic organs from autopsied cadavers and transverse sections were prepared at 10-mm intervals after fixation. The location of the pelvic plexus was then measured on the tissue preparations, and compared to that of surgical specimens from rectal cancers with concurrent resection of the pelvic plexus. The pelvic plexus was located from 3.3±1.2cm above to 2.3±1.9 cm below the peritoneal reflection in the autopsied specimens. The average distances between the muscularis propria and the pelvic plexus in the autopsied specimens and surgical specimens were 8.3±3.5 mm and 14.7±4.5 mm, respectively, showing a significant difference (P<0.05). Pelvic plexuses were located about 10 mm from the outer margin of rectal muscularis propria. These findings indicate that concurrent resection of the pelvic plexus may be required to secure sufficient surgical clearance in pT3 rectal cancers, especially those invading deeply beyond the muscularis propria (a₂).     

经肛门全直肠系膜切除术研究进展

低位直肠癌的治疗方式不仅仅要考虑肿瘤的完整切除,保留肛门生理功能也是一个至关重要的问题。随着对直肠肛管以及盆底肌肉神经局部解剖生理研究的深入,伴随医疗技术的进步,针对低位直肠癌保肛的各种手术方式应运而生,目前较为成熟的手术方式主要有结肠肛管吻合术（Parks术）、经括约肌间切除术（ISR）、经肛门全直肠系膜切除术（TaTME）等。其中,TaTME是体现经自然腔道内镜外科手术（NOTES）的一种理念和手术方式。目前关于TaTME在直肠恶性肿瘤中应用的安全性及有效性在国际上尚存在一定争议,本综述旨在通过查阅国内外现有关于TaTME的相关文献,总结探讨TaTME在低位直肠癌治疗中的安全性、有效性以及未来的发展趋势。     

A new technique to achieve sufficient mesorectal excision in upper rectal cancer

BACKGROUND: Appropriate partial mesorectal excision (PME) is extremely important for prevention of local recurrence even in upper rectal cancer. However, it is not always easy to conduct PME in the narrow pelvic cavity. We devised a new surgical technique that involves a rectal transection followed by PME. METHODS: After rectal mobilization in the layer targeted for total mesorectal excision, only the rectal wall was bluntly dissected at an appropriate distance from the tumor. Initial transection of the rectum allows drawing the rectum toward the anal side so that the mesorectum can be confirmed with a good visual field. Excision of the mesorectum was easy, and it could be resected in a short time. RESULTS: This technique was conducted on seven patients with upper rectal cancer and on four patients with rectosigmoid cancer. Separation of the rectal wall was comparatively easy, and we had no incidence of wall injury. The average distance from the rectal stump to the distal mesorectum in the freshly resected specimen was 15 mm, indicating satisfactory PME. CONCLUSIONS:This easily performed method is a promising procedure for achieving sufficient PME in upper rectal cancer.     

经肛门直肠全系膜切除术现状及研究进展

全直肠系膜切除理念的提出是直肠癌外科治疗一项重要的变革,伴随腹腔镜技术的应用,使得腹腔镜下经肛门全直肠系膜切除术越来越被外科医师关注。对于肿瘤较大、骨盆狭小的男性肥胖患者,中低位直肠的暴露和分离仍然是个问题,而腹腔镜下完全经肛门全直肠系膜切除术可能是一种潜在的解决途径,在达到直肠癌根治切除要求的同时又尽可能保留肛门、避免腹部切口,患者不仅术后生活质量得到提高,而且美观。随着操作器械、手术平台的不断完善及经验总结后,该术式将有望在中低位直肠癌治疗中占重要地位。     

Indications for and limitations of low anterior resection

The indications for low anterior resection are based mainly on tumor location, penetration depth, histology, macroscopic appearance, etc. Patients with tumors located 2 cm above the puborectal muscle by digital examination can undergo low anterior resection. Distal surgical margins should be at least 1 cm from the tumor in cases of differentiated cancer and localized tumors of stage T2 or less and more than 2 cm in poorly differentiated cancer and tumors of stage T3 or greater with total mesorectal excision (TME). Longer distal surgical margins should be provided in patients with unlocalized tumors and extensive node metastasis. The final decision on whether low anterior resection is appropriate should be made after mesorectal preparation down to the levator muscles with adequate surgical margins. Low anterior resection is contraindicated in patients with poor anorectal function and high age. A rectal stump 1 to 2 cm from the dentate line should be maintained for better postoperative anorectal function if radical excision can still be performed.     

Endoluminal pressure: risk factor for anastomotic dehiscence in rectal carcinoma. Preliminary results

The aim of this work was to evaluate the risk factors for anastomotic leakage with particular reference to endoluminal pressures in patients undergoing surgery for colorectal cancer between february 1998 and september 2000. In this preliminary report a total of 120 patients were identified; 96 patients were treated with a total mesorectal excision (with anastomosis less than 10 cm from the anal margin) for rectal cancer and 33 with a partial mesorectal excision (with anastomosis of the superior rectum) for rectosigmoid carcinoma. The leakages were observed in 10.4% of patients and the incidence of this complication was 15.6% in patients with rectal cancer. Using a transanal tube (7 x 2 cm) which reduces endoluminal pressure close to the anastomosis, a significant reduction in the number of leakages was observed. The authors suggest that the transanal tube represents a useful aid in resolving the problem of anastomotic leakage in rectal cancer and stress the importance of this simple, cheap surgical technique.     

Rectum carcinoma. Optimizing therapy by deep resection or excision]

Abdominoperineal excision of the rectum has been the surgical treatment of choice for rectal cancer of the middle and lower third for decades. However, subsequent to technical developments, particularly stapling instruments, sphincter saving procedures such as low anterior or intersphincteric resection superseded abdominoperineal excision in the majority of tumors of the middle and even lower third of the rectum. Within the last seven years (1990-1997), 253 patients with distal rectal cancer underwent surgery--in 204 patients surgery was carried out for the cure of malignancy, whereas in 49 patients surgery was performed for palliation. In the meantime, the rate of abdominoperineal excision with permanent stoma was steadily decreased from 25% (1990-1993) to 9% (1994-1997). Concerning oncologic quality, sphincter saving resections showed evidence that cure rates (3- and 5-year survival) were not compromised by these techniques; conversely, sphincter saving resections offered oncologic cure rates superior to abdominoperineal excision of the rectum. Complete lymphadenectomy with high ligation of the inferior mesenteric artery and total mesorectal excision (TME) are fundamental components of this approach. Moreover, the adverse effects of a permanent colostomy and the consecutively diminished quality of life following abdominoperineal excision can be avoided in approximately 80% of cases. In conclusion, at present 80-85% of rectal carcinomas of the middle or lower third can be surgically treated by sphincter saving low resections without compromising oncologic radicality.