Is There a Best Abdominal Surgery for Rectal Cancer in Patients Whose Rectum is Removed?

Q: Is there a best abdominal surgery for rectal cancer in patients whose rectum is removed?

A: There is absolutely a best practice. It’s total mesorectal excision (TME) with a goal — based on preoperative imaging with magnetic resonance — to have a negative circumferential excision margin. That may mean going beyond the normal TME plane and removing other organs en bloc to ensure a negative circumferential margin.

What is less clear is the best surgical approach. My interpretation of the literature is that COLOR II and other randomized trials show oncological equivalence for laparoscopy. Therefore, it is my first approach, when possible, as we provide the patients other short-term benefits, such as earlier recovery, and fewer complications.

Transanal TME is a new option, which I believe is helpful for heavier patients with lower tumors. However, we await the results of the COLOR III trial. Early results from nonrandomized trials look promising however.

I reserve open surgery for complex reoperative cases, complex multivisceral resections or the highest BMI patients. I don’t use robotics because I believe the ROLARR trial shows equivalence with laparoscopy and has not shown a value equation to support the extra expense and operative time of robotics, outside of research studies. The ROLARR trial did show a reduced conversion rate compared to laparoscopic surgery in some subgroups, but these were generally heavier males who one could do with transanal TME. Robotics would have a number needed to treat (NNT) of about 11, which makes it a difficult value proposition.

So overall, a carefully performed, laparoscopic TME by an experienced surgeon who is part of a multidisciplinary care team is best.

— Conor Delaney, MD, PhD
Chairman, Digestive Disease & Surgery Institute
Cleveland Clinic