Multivisceral Resection in Rectal Cancer

The treatment of locally advanced rectal cancer (T3/4 or N1/2) is challenging and requires a multidisciplinary approach including diagnostic radiology, medical oncology, pathology, radiation therapy, and surgery. Unlike many solid tumors, locally advanced or locally invasive rectal cancer is not necessarily unresectable (Lopez 2001). Indeed, over the past 30 years, it has been shown that a significant percentage of even large colorectal tumors remain localized and do not metastasize; therefore, en-bloc resection with clear margins can lead to cure (Lopez 2001; Gebhardt et al. 1999; Nakafusa et al. 2004; Lehnert et al. 2002; Klaassen et al. 2004; Govindarajan et al. 2006). In a study by Spratt and Spjut involving examination of more than 1,000 colorectal tumors, two-thirds of the large or locally invasive tumors had reportedly not metastasized to even locoregional lymph nodes (Spratt and Spjut 1970). However, it is important to recognize that up to 15% of rectal cancer tumors will be adherent to or invasive into adjacent pelvic organs. Since the surgeon cannot easily differentiate a malignant fistula from an inflammatory adhesion (Gebhardt et al. 1999), and because separation of a malignant fistula can lead to local tumor dissemination and recurrence, multivisceral resection should be considered. Advanced planning, with strict adherence to the principles of surgical oncology, is necessary when treating these difficult cases. Although multivisceral resection, compared with standard resection, can improve outcome of advanced lesions, these are complex procedures associated with increased morbidity and even perioperative mortality (Birkmeyer et al. 2003, 2007). It is critical to anticipate the need for assistance in order to mobilize a large, multidisciplinary surgical team, which may include colorectal, urologic, gynecologic, orthopedic, neurosurgical, and plastic surgeons. In addition, it is important to recogn ize the need for perioperative care including radiologists, intensivists, and specialized nurses as well as occupational and physical therapists (Madoff 2006). Multivisceral pelvic resections are a challenge not only for surgeons, but also for the patient and the healthcare system. For these reasons, it is both rational and necessary to treat such advanced lesions at specialty centers (Madoff 2006). This chapter provides a general overview of the role of multivisceral resection during treatment, as well as strategies and guidelines to be used when approaching patients with locally advanced rectal cancer.