Early rectal cancer management

Since the early1990s there has been an overhaul in the approach to rectal cancer with the work of Bill Heald teaching and encouraging surgeons to practice a meticulous approach to rectal cancer surgery, termed Total Mesorectal Excision (TME).1 This involved removing the rectum and the surrounding package of fat enclosed by what is termed the mesorectal fascial ‘envelope’ (the mesorectum), which generally contains the nearest and most commonly involved cancerous lymph nodes.

We now know that failing to completely remove this fatty package at the time of surgery means that cancerous lymph nodes may be left behind and the patient is at risk of cancer recurrence. TME surgery has been shown to improve a patient’s prognosis but it is a major operation – requiring removal of the rectum (and thus a bowel resection) with the potential for a permanent stoma. If the bowel is rejoined there is a risk of the join breaking down (anastomotic leak) and, in many patients, poor control of bowel function leading to ‘toilet dependency’occurs. Additionally, some reports suggest up to 1 in 20 patients do not survive an operation to remove a rectal cancer.2

Since the early 1990s, there has been increasing evidence that diligent surveillance of the inside of the bowel by colonoscopy allows pre-cancers, polyps and early cancers to be identified and completely removed before the patient develops symptoms.3 Monitoring the bowel with this ‘endoluminal technique’ has been shown to pick up cancers earlier with an associated improvement in colon and rectal cancer survival outcomes.4