Rectal Cancer Treatment In The Present Day: Organ Conservation And Beyond

A little over a century ago, cancer of the rectum was incurable. Not only was the disease fatal, but in later stages, it was often accompanied by profound physical agony and pain, apart from indignity caused by incontinence to stools.

In 1907, the English surgeon Ernest Miles described an operation for rectal cancer which removed the entire rectum along with the surrounding tissues. For the first time ever, it was possible to cure rectal cancer by this operation, technically called “abdomino-perineal excision” – since the rectum was surgically removed through a combined approach – both through the abdomen as well as through the perineum (bottom).

The “Miles operation” was a heroic operation – accompanied by much blood loss, big wounds in the abdomen and the bottom (requiring several weeks to heal), impotence, and high rates of post-operative urinary difficulties (due to damage to the delicate pelvic autonomic nerves).

But the most distressing outcome of this operation was the inevitable need for a permanent colostomy. (an opening in the front of the abdomen to collect stools).  Rectal cancer surgery came to be associated with a colostomy, and its attendant challenges.

Also, notwithstanding its success in curing many people of a hitherto incurable cancer, the disease would recur in quite a few.

Despite the above drawbacks, there was no alternative treatment for rectal cancer, and the abdominoperineal excision continued to be performed as described by Miles for most of the previous century.

Over the last three decades, several advances have contributed to better outcomes – both in terms of cure rates as well as reduced mortality and morbidity.

  1. A better understanding of surgical anatomy and pathology, (work pioneered by the UK surgeon Professor Heald)
  2. Use of neo-adjuvant and adjuvant therapies (radiation and chemotherapy in addition to surgery).
  3. Use of devices like surgical staplers, that facilitate rejoining of the intestine (anastomosis) deep in the pelvis.
  4. Use of minimally invasive techniques, which enable close-up access and magnified viewing of the delicate pelvic structures, especially the anatomic planes and autonomic nerves.
  5. Focus on surgical specialization and training.

Currently, the majority of people with rectal cancer are able to retain their normal passage without the need for a permanent colostomy. In addition, the rates of urinary and sexual problems are minimal. And most importantly, with judicious use of adjuvant therapies and better surgical techniques, the cure rates for rectal cancer are higher than ever before.



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