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Overview of surgery for the treatment of primary rectal adenocarcinoma

Ronald Bleday, MD
David Shibata, MD
Section Editor
Kenneth K Tanabe, MD
Deputy Editor
Wenliang Chen, MD, PhD


Surgery is the cornerstone of curative therapy for patients with resectable rectal adenocarcinoma [1]. The operative procedure selected depends upon stage, size, and location. Superficial (T0/T1) and small (<3 cm) cancers may be effectively managed with limited surgery, such as local excision. However, most patients have more deeply invasive tumors that require a sphincter-sparing procedure or abdominoperineal resection (APR). Locally advanced tumors that are adherent or fixed to adjoining structures (eg, sacrum, pelvic sidewalls, prostate, or bladder) require a more extensive resection.

Primary rectal squamous cell carcinomas, which are very rare, can be difficult to distinguish from anal cancers and they are treated according to the same approach as anal cancer, with initial chemoradiotherapy rather than surgery. (See "Clinical features, staging, and treatment of anal cancer", section on 'Rectal squamous cell cancers'.)


Patients with distal rectal adenocarcinoma and nonaggressive features can be treated by local excision, including the transanal, transsphincteric, and posterior parasacral approaches. Local excision permits removal of both the tumor and adjoining rectal tissue in one specimen without tumor fragmentation, and allows assessment of inked margins, histologic differentiation, vascular involvement, and depth of invasion. Local excision, however, is not a treatment option for patients with middle or proximal rectal lesions.

The selection criteria for performing a local excision alone (eg, T1 lesion, less than 3 cm in diameter) are reviewed separately (table 1). (See "Surgical resection of primary rectal adenocarcinoma", section on 'Local excision'.)

Select patients (eg, elderly with comorbid illnesses, refusal of major resection) with tumors deeper than T1 can be treated with a local excision if used in conjunction with radiation and/or chemotherapy, administered preoperatively or postoperatively. (See "Adjuvant therapy for resected rectal adenocarcinoma", section on 'Adjuvant chemoradiotherapy for T2-3 rectal cancer after local excision'.)


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Literature review current through: Sep 2016. | This topic last updated: Nov 5, 2015.
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