Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jun 27, 2017; 9(6): 139-148
Published online Jun 27, 2017. doi: 10.4240/wjgs.v9.i6.139
Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery
Joseph M Plummer, Pierre-Anthony Leake, Matthew R Albert
Joseph M Plummer, Pierre-Anthony Leake, Department of Surgery, Radiology, Anaesthesia and Intensive Care, University of the West Indies, Kingston 7, Jamaica
Matthew R Albert, Center for Colon and Rectal Surgery, Department of Colon and Rectal Surgery, Florida Hospital, Orlando, FL 32803, United States
Author contributions: Plummer JM, Leake PA and Albert MR contributed equally to the writing of this manuscript.
Conflict-of-interest statement: Plummer JM and Leake PA have no relevant disclosures. Albert MR’s disclosures are: Applied Medical - Consultant; ConMed - Consultant and Surgiquest - Consultant.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Joseph M Plummer, Senior Lecturer, Department of Surgery, Radiology, Anaesthesia and Intensive Care, University of the West Indies, Regional Headquarters, Kingston 7, Jamaica.
Telephone: +876-9271279 Fax: +876-9704302
Received: January 6, 2017
Peer-review started: January 10, 2017
First decision: February 17, 2017
Revised: March 19, 2017
Accepted: April 6, 2017
Article in press: April 8, 2017
Published online: June 27, 2017

Over the last decade, with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer, there has been a significant increase in the literature regarding treatment options available to patients affected by this disease. That treatment related decisions should be made at a high volume multidisciplinary tumor board, after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision (TME) are accepted standard of care. More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders, which may be appropriate in 20% of patients. Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only, with transanal minimal invasive surgery (TAMIS) because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon, emerging as the leading option. Recent trials have raised concerns about the oncologic outcomes of the standard “top-down” TME hence transanal TME (TaTME “bottom-up”) approach has gained popularity as an alternative. The challenges are many, with a dearth of evidence of the oncologic superiority in the long-term for any given option. However, this review highlights recent advances in the role of chemoradiation only for complete pathologic responders, TAMIS for highly selected early rectal cancer patients and TaTME as options to improve cure rates whilst maintaining quality of life in these patients, while we await the results of further definitive trials being currently conducted.

Keywords: Rectal cancer, Watchful waiting, Transanal minimal invasive surgery, Transanal total mesorectal excision

Core tip: Over the last decade several additional surgical options have become available in the management of rectal cancer. These extend from non-surgical management with chemoradiation only, local excision for selected cases of early rectal cancer and the standard total mesorectal excision but now by a transanal approach. Although long-term outcome studies are ongoing, it is the duty of the multidisciplinary team treating these patients to be familiar with these options, as they may be of benefit to selected patients with this disease.