Tumor-specific Mesorectal Excision Research Articles

Short-term outcomes of robotic tumor-specific mesorectal resection of rectal cancer: surgical techniques in mesorectal division using rolling division of the mesorectum.

This study aims to report our surgical techniques for robot-assisted laparoscopic anterior resection, specifically focusing on mesorectal division using rolling division of the mesorectum, and to elucidate short-term outcomes at a single institution. Tumor-specific mesorectal excision (TSME) is commonly performed for resection of a tumor located in the upper rectum. However, especially in a narrow pelvis, it is difficult to perform appropriate mesorectal division at an adequate distance from the tumor in robot-assisted laparoscopic anterior resection. Retrospective case series of patients with rectal cancer who underwent robot-assisted TSME using rolling division of mesorectum. Patient characteristics, perioperative clinical results, surgical and pathological details were recorded. A total of 198 patients underwent robot-assisted TSME for rectal cancer using rolling division of mesorectum between May 2019 and December 2023.The tumor was located in the upper rectum in 45 patients, middle rectum in 115 patients and lower rectum in 38 patients. The types of resections were 40 high anterior resection and 158 low anterior resections. The median operation time was 175 (range 109-310) min, and median mesorectal division time was 24 (range 15-45) min. Median blood loss was 3 (range 0-20) ml; no patients required blood transfusion. The overall complication rate of Clavien-Dindo classification grades I-IV was 7.1%. Anastomotic leakage was observed in two patients (1.0%) with grade III. There was no surgical mortality in this series. This robotic technique for anterior resection is a feasible and reliable procedure for achieving sufficient and safe TSME in this cohort.

Intramural cancer recurrence in the rectum after curative surgery for proximal sigmoid colon cancer: a case report

BackgroundIntramural metastasis distant from the primary tumor is rare in colorectal cancer. Here, we present a notably rare and probably the first case of asynchronous intramural recurrence in the rectum after curative surgery for proximal sigmoid colon cancer.Case presentationA 44-year-old man underwent curative sigmoidectomy for proximal sigmoid colon cancer with T3N0M0, Stage IIA tubular adenocarcinomas. After 15 months, the tumor marker level had increased, and positron emission tomography-computed tomography (PET-CT) revealed abnormal fluorodeoxyglucose uptake in the rectum; colonoscopy revealed a submucosal tumor (SMT)-like lesion in the upper rectum, and biopsy revealed a tubular adenocarcinoma. We performed curative low anterior resection with tumor-specific mesorectal excision (TSME). The SMT-like tumor was located approximately 20 cm from the initial sigmoid colon anastomosis (i.e., at least 20 cm distal to the initial sigmoid colon cancer). The pathological findings revealed cancer cells with the same features as the initial sigmoid colon cancer, only in the intestinal wall but not in the mucosa and extramural tissue. Therefore, the lesion was determined to be an intramural recurrence.After 24 months, lung recurrence, and local recurrence, which might have involved the lymph nodes in the preserved mesorectum after TSME at the bottom of the pelvis was detected on PET-CT. Hence, we started systemic chemotherapy.ConclusionsThis case report suggests that PET-CT and short-interval repeat colonoscopy may help detect a rare intramural recurrence. A long distal margin may be necessary to achieve local control in the rectal resection for intramural recurrence.

Short-term outcomes of neoadjuvant chemotherapy with capecitabine plus oxaliplatin for patients with locally advanced rectal cancer followed by total or tumor-specific mesorectal excision with or without lateral pelvic lymph node dissection.

Background: The standard strategy in Japan for locally advanced rectal cancer is total mesorectal excision plus adjuvant chemotherapy. However, large tumors significantly restrict pelvic manipulation of the distal side of the tumor during surgery; therefore, from an oncological point of view, it is better to shrink the tumor as much as possible preoperatively to optimize the circumferential resection margin. In recent years, advances in systemic chemotherapy have significantly improved the tumor reduction effect, enabling such drug therapy prior to surgery for locally advanced rectal cancer. We herein retrospectively evaluated the clinical, short-term outcomes of patients treated by neoadjuvant chemotherapy (NAC) using capecitabin and oxaliplatin (CAPOX), focusing on overall safety as well as clinical and pathological staging responses to NAC.Methods: We applied the preoperative chemotherapy protocol to T3-4, any N, M0 or M1a (with resectable metastases) (UICC 8th) Ra/Rb rectal cancers. The chemotherapy regimen consisted of four cycles of CAPOX. After NAC, curative intent surgery with total mesorectal excision/tumor-specific mesorectal excision with/without metastasectomy was performed. Adverse effects (AEs) and compliance with NAC, surgical complications, clinical and pathological staging were evaluated. All patients undergoing the protocol between January 2017 and June 2021 at Fukushima Medical University were enrolled.Results: Twenty cases were enrolled. No severe AEs were observed either preoperatively or perioperatively. Preoperative assessment of NAC showed no cases of progressive disease (PD). Radical resection was achieved in all cases. Histological therapeutic grading after NAC revealed one grade 3, four grade 2, three grade 1b, eleven grade 1a and one grade 0 among all cases.Conclusion: This study suggests that NAC for locally advanced rectal cancer is likely to be acceptable because there were no severe AEs pre- or perioperatively, radical resection was achieved in all cases, and there were no cases of PD.

Risk factors of low anterior resection syndrome after miniinvasive restorative rectal resection.

Over the last decades outcomes for rectal cancer surgery have improved with increasing survival and lower recurrence rates. Nevertheless, functional disorders are still frequent. Low anterior resection with total mesorectal excision (TME) in patients with rectal cancer has improved oncological outcomes. However, most of them will have significant changes in quality of life, including varying degree of bowel dysfunction. Aim of this study was to analyse prevalence of LARS (low anterior resection syndrome) in patients with rectal cancer after miniinvasive restorative resection and to define its risk factors. Between March 2016 and June 2018, patients who underwent elective miniinvasive (laparoscopic or robotic) rectal resection were enrolled. Bowel dysfunction was evaluated by LARS questionnaire and filled out 6, 12, and 24 months after primary operation or after ileostomy closure. 98 patients completed the questionnaires - 58 laparoscopic operations, 34 robotic and 6 open procedures. 69 patients underwent TME, tumor-specific mesorectal excision 21 patients. 8 patients underwent transanal TME. The clinical characteristics, surgical perioperative and postoperative outcomes did not differ between these groups. Only, significantly more patients underwent neoadjuvant radiotherapy in the robotic group (p=0.004). 59.8% patients reported major LARS 6 months after surgery and 29.7% after 24 months. Protentional risk factors are age (p.

Pelvic local recurrence as first relapse predicts prognosis for clinical stage II/III lower rectal cancer: A clinicopathological investigation.

The present study investigated the association between the mode of tumor recurrence and prognosis in 123 patients with clinical stage II/III rectal cancer. In the past 10 years, patients received systemic chemotherapy following radical (R0, with no macroscopic residual tumor lesions) resection using total or tumor-specific mesorectal excision. Patients with rectosigmoid cancer and T4 + chemoradiation therapy were excluded from the present study. The 5-year relapse-free survival rate (5Y-RFS), 5-year overall survival rate (5Y-OS), and associations between early post-operative complications, recurrence mode and prognosis, as well as the 5Y-OS of patients with relapsed cancer, were calculated. The overall 5Y-RFS and 5Y-OS were 71.4 and 83.5%, respectively, and the overall recurrence rate was 22.8% (28/123 patients). Among relapses, remote metastases were observed in 17/123 patients (13.8%): The lung in 8 patients (6.5%), the liver in 5 patients (4.1%) and elsewhere in 4 patients (3.3%). A total of 11 patients (8.9%) had pelvic local recurrence as the first relapse, which was located anterior to the sacrum in 7 patients (5.7%), at the anastomosis site in 2 patients (1.6%), and in the inner pelvis in 2 patients (1.6%). Among relapsed patients, the 5Y-OS was 69.3% in those with distant metastases and 27.3% in those with local relapse (P=0.02; no significant differences in patient demographics). The results indicated that advanced rectal cancer and control of pelvic local recurrence are manageable by R0 resection and postoperative chemotherapy. However, for patients whose initial relapse was pelvic local recurrence, the relapsed tumor initiated a new metastatic cascade to organs, such as the lung and liver, and affected prognosis.

Surgical technique for mesorectal division during robot-assisted laparoscopic tumor-specific mesorectal excision (TSME) for rectal cancer using da Vinci Si surgical system: the simple switching technique (SST).

In a narrow pelvic cavity, performing sufficient tumor-specific mesorectal excision (TSME) is difficult. Even in robot-assisted laparoscopic surgery (RALS), mesorectal division is difficult in a narrow pelvic cavity. To overcome this difficulty, we invented a novel method of mesorectal division. In this new approach, we switched the fenestrated bipolar forceps and the double-fenestrated forceps with each other so that both instruments were placed on the same (right) side of the patient. After the mesorectal fat and vessels were coagulated using the fenestrated bipolar forceps, coagulated tissues were divided using the monopolar scissors in the same direction. We named this technique the "simple switching technique (SST)". We retrospectively collected data and evaluated the usefulness of SST in 24 consecutive patients who underwent RALS TSME between July 2018 and January 2020. Twelve patients underwent SST, and 12 patients underwent other conventional surgical methods (non-SST). The median operation time for mesorectal division was 809.5s (range 395-1491s) in the SST group and 985.5s (range 493-2353s) in the non-SST group. The coefficient of variation for non-SST was 0.545, which was > 1.5 times the coefficient of 0.360 for SST. Although no significant differences were found for operation time for mesorectal division, the operation time for mesorectal division by SST tended to be shorter than by non-SST (P = 0.157). No significant differences were found regarding short-term outcomes between the groups. SST is feasible and can be an optional method of mesorectal division in RALS TSME.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

The feasibility of laparoscopic TSME preserving the left colic artery and superior rectal artery for upper rectal cancer.

BackgroundLaparoscopic tumor-specific mesorectal excision (TSME) preserving the left colic artery and superior rectal artery is still a technically challenging procedure. We conducted this study to demonstrate the feasibility of this procedure for upper rectal cancer.MethodsA total of 184 patients with upper rectal cancer were retrospectively analyzed in our cancer center between April 2010 and April 2017. These patients were treated with either laparoscopic TSME (n = 46) or laparoscopic total mesorectal excision (TME) (n = 138). In the TSME group, the left colonic artery and superior rectal artery were preserved while they were not in the TME group.ResultsThe operation time in the TSME group was longer than that in the TME group (218.56 ± 35.85 min vs. 201.13 ± 42.65 min, P = 0.004). Furthermore, the number of resected lymph nodes in the TSME group was greater than that in the TME group (19.43 ± 9.46 vs. 18.03 ± 7.43, P = 0.024). The blood loss between the TSME and TME groups was not significant. No mortality occurred in either the TSME or TME groups. One patient in the TME group underwent conversion to laparotomy. The total postoperative complication rates in the TSME and TME groups were 8.7% and 17.4%, respectively. There was no difference in severe complications between the two groups (anastomotic leakage and stenosis).ConclusionsLaparoscopic TSME preserving the left colic artery and superior rectal artery can be safely conducted for upper rectal cancer.

Surgical treatment of rectal cancer with a Retzius shunt: a case report

BackgroundA case of a short circuit (Retzius shunt) from the inferior mesenteric vein (IMV) to the inferior vena cava (IVC) without accompanying portal hypertension due to liver cirrhosis is rare.Case presentationAn 83-year-old woman who was followed after surgery for thyroid and breast cancer was incidentally found to have rectal cancer on computed tomography (CT). Preoperative three-dimensional CT showed a venous malformation forming a short circuit (Retzius shunt) from the IMV to the IVC. Laparoscopic anterior rectal resection was performed. Operative findings included the Retzius vein crossing the abdominal aorta and the inferior mesenteric artery (IMA) to the IVC and a number of engorged vessels in the mesentery. The Retzius vein and IMA were clipped without major bleeding, and tumor-specific mesorectal excision was then performed. The patient’s postoperative clinical course was good, and she was discharged without complications.ConclusionsPreoperative imaging enabled identification of an unexpected rare disease, thus reinforcing the importance of preoperative imaging.

Utility of preoperative 3-D simulation of laparoscopic lateral pelvic lymph node dissection for advanced rectal cancer: Surgical outcomes of 10 initial cases.

Laparoscopic lateral pelvic lymph node dissection (LPLD) is technically challenging because of the complicated anatomy of the pelvic wall. To overcome this difficulty, we introduced preoperative 3-D simulation. The aim of the study is to investigate the usefulness of preoperative 3-D simulation for the safe conduct of laparoscopic LPLD for rectal cancer. After undergoing colonoscopy, patients were brought to the radiology suite where multi-detector row CT was performed. Three-dimensional images were constructed at a workstation and showed branches of the iliac artery and vein, ureter, urinary bladder, and enlarged lymph nodes. All members of the surgical team participated in preoperative simulation using the 3-D images. A total of 10 patients with advanced lower rectal cancer and enlarged lateral pelvic lymph nodes underwent laparoscopic unilateral LPLD after total mesorectal excision, tumor-specific mesorectal excision, or total proctocolectomy. Four of the 10 patients (40%) had variations in pelvic vascular anatomy. The median operative time for unilateral LPLD was 91 min (range, 66-142 min) and gradually declined, suggesting a good learning curve. The median number of lateral pelvic lymph nodes harvested was nine (range, 3-16). The median estimated blood loss was 13 mL (range, 10-160 mL). No conversion to open surgery or intraoperative complications occurred. No patient had major postoperative complications. Preoperative 3-D simulation may be useful for the safe conduct of laparoscopic LPLD, especially for surgeons with limited prior experience.

Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database.

The aim of this study is to evaluate the oncological outcomes of robotic total mesorectal excision (TME) at an NCI designated cancer center. The effectiveness of laparoscopic TME could not be established, but the robotic-assisted approach may hold some promise, with improved visualization and ergonomics for pelvic dissection. Oncological outcome data is presently lacking. Patients who underwent total mesorectal excision or tumor-specific mesorectal excision for rectal cancer between April 2009 and April 2016 via a robotic approach were identified from a prospective single-institution database. The circumferential resection margin (CRM), distal resection margin, and TME completeness rates were determined. Kaplan-Meier analysis of disease-free survival and overall survival was performed for all patients treated with curative intent. A total of 276 patients underwent robotic proctectomy during the study period. Robotic surgery was performed initially by 1 surgeon with 3 additional surgeons progressively transitioning from open to robotic during the study period with annual increase in the total number of cases performed robotically. Seven patients had involved circumferential resection margins (2.5%), and there were no positive distal or proximal resection margins. One hundred eighty-six patients had TME quality assessed, and only 1 patient (0.5%) had an incomplete TME. Eighty-three patients were followed up for a minimum of 3 years, with a local recurrence rate of 2.4%, and a distant recurrence rate of 16.9%. Five-year disease-free survival on Kaplan-Meier analysis was 82%, and 5-year overall survival was 87%. Robotic proctectomy for rectal cancer can be performed with good short and medium term oncological outcomes in selected patients.

Early Removal of the Urinary Catheter After Total or Tumor-Specific Mesorectal Excision for Rectal Cancer Is Safe.

Total or tumor-specific mesorectal excision can preserve pelvic autonomic nerves during rectal cancer surgery and minimize urinary dysfunction. However, urinary catheterization several days in duration is a common practice after total or tumor-specific mesorectal excision. This study aimed to evaluate the optimal duration of urinary catheterization after total or tumor-specific mesorectal excision for rectal cancer. This is a retrospective review of patients who underwent total or tumor-specific mesorectal excision for rectal cancer. This study was performed in the colorectal division of a university-affiliated hospital. Between March 2009 and February 2013, 236 patients fulfilled the inclusion criteria. Patients who underwent combined pelvic surgery and those who had postoperative complications with a Dindo grade III or more and a known urinary disease were excluded; the remaining 189 patients were evaluated. The primary outcome measure of this study was the incidence of postoperative urinary retention. The incidence of acute urinary retention was 4.8%. Urinary retention was not associated with the postoperative urinary catheterization duration (p = 0.99). Patients were assigned to 2 groups according to urinary catheterization duration (1 vs ≥ 2 days). No significant differences were observed between the 2 groups regarding urinary retention (4.8% for 1 day vs 4.7% for ≥ 2 days; p = 1.0). In a logistic regression analysis, age, sex, ASA classification, surgical procedure, surgical approach, stage, distance from the anal verge, rate of preoperative radiotherapy, duration of urinary catheterization, and time period of surgery were not associated with urinary retention. This was a retrospective, single-center study. There is potential for selection bias. Our study showed that the urinary catheter could be safely removed on the first postoperative day after total or tumor-specific mesorectal excision.

Changing the Way We Manage Rectal Cancer-Standardizing TME from Open to Robotic (Including Laparoscopic).

Standardizing total mesorectal excision (TME) has been a topic of interest since 1979 when Professor Richard J. Heald first described TME and a new approach to rectal cancer. The procedure is optimized only if every one of the relevant factors is tackled with precise attention to detail, so that the preoperative, operative, and postoperative practice is standardized completely. The same concept of TME standardization applies today regardless of technique chosen, that is, open laparoscopic, single-incision laparoscopic surgery, or robotic. This article reviews the relevant operative factors in performing a quality TME, looking at both the oncologic and nononcologic advantages and disadvantages. It supports TME as the standard of care in obtaining a negative circumferential margin for mid and lower-third rectal cancers, and discusses the role of tumor-specific mesorectal excision for upper-third rectal cancers. It discusses the new options and challenges each operative technique holds, and identifies the same standardized principles each must obey to provide the highest quality of oncologic resection. The operative documentation of these critical features from diagnostic workup to pathological reporting is also emphasized.

Modified single stapler technique in anterior resection for rectal cancer.

Technical difficulties during colorectal surgery increase the complication rates. We introduce a modified single stapler technique for patients in whom technical problems are encountered while performing double stapler technique. Before pelvic dissection, descending colon is divided at minimum 10 cm proximal to the tumoral segment. Tumor specific mesorectal excision is performed and two purse string sutures are placed at the distal margin with an interval of 1 - 2 cm. After introducing a circular stapler via the anus, the distal purse string suture is tied around the central shaft of the stapler and the proximal purse string suture around the colonic lumen. After the resection is completed between the two sutures, the anvil shaft is connected to the central shaft and the stapler is closed and fired. None of the patients had an anastomotic leak. This technique may be a safe alternative particularly in patients with narrow pelvis and distal tumors.

Reduced-port laparoscopic surgery for a tumor-specific mesorectal excision in patients with colorectal cancer: initial experience with 20 consecutive cases.

PurposeSingle-port plus one-port, reduced-port laparoscopic surgery (RPLS) may decrease collisions between laparoscopic instruments and the camera in a narrow, bony, pelvic cavity while maintaining the cosmetic advantages of single-incision laparoscopic surgery. The aim of this study is to describe our initial experience with and to assess the feasibility and safety of RPLS for tumor-specific mesorectal excisions (TSMEs) in patients with colorectal cancer.MethodsBetween May 2010 and August 2012, RPLS for TSME was performed in 20 patients with colorectal cancer. A single port with four channels through an umbilical incision and an additional port in the right lower quadrant were used for RPLS.ResultsThe median operation time was 231 minutes (range, 160-347 minutes), and the estimated blood loss was 100 mL (range, 50-500 mL). We transected the rectum with one laparoscopic stapler in 17 cases (85%). The median time to soft diet was 4 days (range, 3-6 days), and the length of hospital stay was 7 days (range, 5-45 days). The median total number of lymph nodes harvested was 16 (range, 7-36), and circumferential resection margin involvement was found in 1 case (5%). Seven patients (35%) developed postoperative complications, and no mortalities occurred within 30 days. During the median follow-up period of 20 months (range, 12-40 months), liver metastasis occurred in 1 patient 10 months after surgery, and local recurrence was nonexistent.ConclusionRPLS for TSME in patients with colorectal cancer is technically feasible and safe without compromising oncologic safety. However, further studies comparing RPLS with a conventional, laparoscopic low-anterior resection are needed to prove the advantages of the RPLS procedure.

Robotic Rectal Cancer Resection: A Retrospective Multicenter Analysis.

Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study. Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients. Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times. Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.

The Magnetic Resonance Imaging-Based Approach for Identification of High-Risk Patients With Upper Rectal Cancer

To assess the efficacy of preoperative magnetic resonance imaging (MRI) in identifying upper rectal cancer patients who are at high risk for local recurrence. 110 upper rectal cancer patients with locally advanced (pT3-4N0 or pTanyN+) tumors treated with tumor-specific mesorectal excision and no adjuvant radiotherapy were identified from an institutional database at a large academic medical center in Korea. Information on the extent of mesorectal invasion, sacral-side involvement was collected from preoperative MRI. At a median follow-up of 47 months, 5 patients (4.5%) experienced local recurrence (LR). LR rates for patients with intermediate risk (T1-2/N1, T3N0), moderately high risk (T1-2/N2, T3N1, T4N0), and high risk (T3N2, T4/N1-2) were 3%, 4.8%, and 8.7%, respectively. Patients who did not have sacral-side involvement or mesorectal invasion of 5 mm or less did not experience LR. The patients with sacral-side involvement and intermediate risk, moderately high risk, and high risk had an LR rate of 4.2%, 5.6%, and 10%, respectively, or 11.1%, 33.3%, and 18.2%, respectively, when combined with those with mesorectal invasion of greater than 5 mm. Multivariate analyses demonstrated the presence of both sacral-side location and mesorectal invasion of greater than 5 mm was significantly associated with adverse disease-free and overall survival (P < 0.05). Patients with mesorectal invasion of greater than 5 mm and sacral-side involvement identified on MRI were at an increased risk of local recurrence. The detection of these features on MRI provides prognostic information that is not available in conventional risk classification systems. Improved identification of a high-risk subset of upper rectal cancer patients may guide indications for preoperative chemoradiotherapy in this subset.

Outcome of Tumor-Specific Mesorectal Excision for Rectal Cancer: The Impact of Laparoscopic Resection

The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center. We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival. A total of 1,063 patients underwent rectal resection with 470 (44.2%) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8% was noted, with an anastomotic leak rate of 3.87% in the open group and 2.97% in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis. We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.

Current issues in locally advanced colorectal cancer treated by preoperative chemoradiotherapy

In patients with locally advanced rectal cancer, preoperative chemoradiotherapy has proven to significantly improve local control and cause lower treatment-related toxicity compared with postoperative adjuvant treatment. Preoperative chemoradiotherapy followed by total mesorectal excision or tumor specific mesorectal excision has evolved as the standard treatment for locally advanced rectal cancer. The paradigm shift from postoperative to preoperative therapy has raised a series of concerns however that have practical clinical implications. These include the method used to predict patients who will show good response, sphincter preservation, the application of conservative management such as local excision or "wait-and-watch" in patients obtaining a good response following preoperative chemoradiotherapy, and the role of adjuvant chemotherapy. This review addresses these current issues in patients with locally advanced rectal cancer treated by preoperative chemoradiotherapy.

Modern rectal cancer surgery—Total mesorectal excision—The standard of care

The literature has repeatedly shown the superiority of total mesorectal excision (TME) for rectal cancer in reducing the incidence of local recurrence (LR) and improving long-term survival compared to conventional blunt rectal dissection. This article reviews the history of surgery for rectal cancer, supports TME as the standard of care in obtaining a negative circumferential margin (CRM) for mid- and lower-third rectal cancers, discusses the drawbacks of TME, the role of tumor-specific mesorectal excision for upper-third rectal cancers and laparoscopic TME, and emphasizes the need for a selective role of chemoradiation with TME for rectal cancer. The need for standardizing TME in the United States with pathological specimen quality analysis and reporting of the completeness of the TME specimen is also emphasized.