Low rectal cancer: classification and standardization of surgery

Dis Colon Rectum. 2013 May;56(5):560-7. doi: 10.1097/DCR.0b013e31827c4a8c.


Background: Surgical treatment of low rectal cancer is controversial, and one of the reasons is the lack of definition and standardization of surgery in low rectal cancer.

Objective: We classified low rectal cancers in 4 groups with the aim of demonstrating that most patients with low rectal cancer can receive conservative surgery without compromising oncologic outcome.

Design: Patients with low rectal cancer <6 cm from anal verge were defined in 4 groups: type I (supra-anal tumors: >1 cm from anal ring) had coloanal anastomosis, type II (juxta-anal tumors: <1 cm from anal ring) had partial intersphincteric resection, type III (intra-anal tumors: internal anal sphincter invasion) had total intersphincteric resection, and type IV (transanal tumors: external anal sphincter invasion) had abdominoperineal resection. Patients with ultra-low sphincter-preserving surgery (types II-III) were compared with those with conventional sphincter-preserving surgery (type I).

Outcome measures: Postoperative mortality, morbidity, surgical margins, local and distant recurrence, and survival were analyzed.

Results: Of 404 patients with low rectal cancer, 135 were type I, 131 type II, 55 type III, and 83 type IV. There was no difference in local recurrence (5% to 9% vs 6%), distant recurrence (23% vs 23%), and disease-free survival (70%-73% vs 68%) at 5 years between ultra-low (types II-III) and conventional (type I) sphincter-preserving surgery. Predictive factors of survival were tumor stage and R1 resection but not the type of tumor or type of surgery.

Limitations: This study is limited by the retrospective analysis of a database, obtained from a single institution and covering a 16-year period.

Conclusion: Classification of low rectal cancers and standardization of surgery permitted sphincter-preserving surgery in 79% of patients with low rectal cancer without compromising oncologic outcome. This new surgical classification should be used to standardize surgery and increase sphincter-preserving surgery in low rectal cancer.

MeSH terms

  • Adenocarcinoma* / classification
  • Adenocarcinoma* / pathology
  • Adenocarcinoma* / surgery
  • Adult
  • Aged
  • Aged, 80 and over
  • Anal Canal / surgery*
  • Anastomosis, Surgical / methods
  • Cohort Studies
  • Disease-Free Survival
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Neoplasm Recurrence, Local
  • Prognosis
  • Rectal Neoplasms* / classification
  • Rectal Neoplasms* / pathology
  • Rectal Neoplasms* / surgery
  • Rectum / surgery*
  • Retrospective Studies
  • Treatment Outcome
  • Young Adult