Chapter 24. Operative Management of Rectal Tumors

Transanal Excision of Tumor

• Stage T1 tumors:
  • Mobile and < 4 cm in diameter.
  • Involving < 40% of the rectal wall circumference.
  • Located within 6 cm of the anal verge.
• Well or moderately differentiated histology only.
• Absence of vascular and lymphatic invasion.
• No evidence of nodal involvement on preoperative rectal ultrasound or MRI.

Low Anterior Resection (LAR) with Total Mesorectal Excision

• Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained within 2 cm of the anal sphincter in moderately or well-differentiated tumors or within 5 cm for poorly differentiated tumors.

Abdominoperineal Resection (APR) with Total Mesorectal Excision

• Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

Transanal Excision of Tumor

• Tumors stage greater than T1N0M0.
• Fixed tumors.
• Tumors > 4 cm in diameter or involving > 40% of the circumference of the rectal wall.
• Tumors located > 6 cm from the anal verge.
• Tumors with poorly differentiated histology or angiolymphatic invasion, or those that show evidence of nodal involvement on preoperative rectal ultrasound or MRI.

LAR with Total Mesorectal Excision

• Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

APR with Total Mesorectal Excision

• Malignant lesion of the lower rectum diagnosed by evaluation of a tissue biopsy specimen showing local invasion into the pelvic sidewall or pelvis that could benefit from neoadjuvant treatment to facilitate possible curative resection.

Transanal Excision of Tumor

• For posterior lesions, the patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups.
• For anterior lesions, the prone jackknife position is preferred.
• Sequential pneumatic compression devices should be applied.

LAR or APR with Total Mesorectal Excision

• The patient should be in a supine lithotomy position in gentle Trendelenburg using well-padded stirrups.
• Sequential pneumatic compression devices should be applied.
• A Foley catheter and nasogastric or orogastric tube should be placed, especially if mobilization of the splenic flexure is contemplated.
• Consideration should also be given to the placement of a left ureteral stent if a difficult pelvic dissection is anticipated.

• Early ambulation is encouraged and diet is advanced as soon as tolerated.
• Patients requiring abdominal incision receive epidural analgesia and are transitioned to oral pain medications as soon as they can tolerate solids.
• Patients with ileostomies may require aggressive management of fluid status after the resumption of bowel function. We promote aggressive isotonic liquid consumption by the patient, with avoidance of caffeine and chocolate, and prefer first to use fiber bulking agents, followed by the addition of the antimotility agent loperamide.
• Daily examination of the perineal wound is mandatory following APR, and sitting should be discouraged for the first 5 postoperative days. Walking, however, should be aggressively encouraged.
• Pelvic drains are generally removed on postoperative day ...