Chirurgie du cancer du rectum

Surgical resection is the only curative procedure for carcinoma of the rectum. Heald's development of total mesorectal excision has made it the standard approach for mobile, non-fixed tumors; it permits optimal local control with less than 10% local recurrence at five years and minimizes nerve damage and genito-urinary complications. Although initial short-term results of laparoscopic approaches are very promising, the final role of laparoscopy has not yet been established. Neo-adjuvant radiotherapy should be proposed for locally advanced (T3, T4, and/or N+) tumors of the low and mid-rectum. Radiochemotherapy coupled with intersphincteric dissection offers hope for sphicter-sparing extirpation of even the lowest of rectal cancers. Local resection through a trans-anal approach may be considered for small (<3 cm.), mobile, well-differentiated tumors lying within 8 cm. of the anal verge if rectal echo-endoscopy shows an in-situ tumor or a T1 lesion with no evidence of lymphadenopathy. Future strategies may enlarge the indications for local resection if and when radiochemotherapy can achieve a complete local response (tumor sterilization).