Direct intraoperative assessment of total mesorectal excision specimens by expert pathologists in patients with very low rectal cancer prevents unnecessary abdominoperineal resections

Int J Colorectal Dis. 2020 Apr;35(4):755-758. doi: 10.1007/s00384-020-03514-0. Epub 2020 Jan 25.


Purpose: In patients with low rectal cancer, the intraoperative assessment of sufficient distal resection margins can be challenging. The assessment determines whether reconstruction can be performed or whether permanent colostomy is required. The goal of the present study was to evaluate intraoperative assessment of the total mesorectal excision (TME) specimen during an interruption of the operation.

Methods: The intraoperative strategy of eight patients with low rectal cancer was evaluated. In all cases, intraoperative pathological assessment of the TME specimen by an expert pathologist together with the surgeon was performed. Assessment of the distance of the tumor to the resection margin was measured macroscopically as well as microscopically.

Results: All patients underwent neoadjuvant chemoradiation. The tumor was located at an average 4.8 ± 1.4 cm from the anal verge. In all cases, preoperative MRI revealed mrT3 tumors. The intraoperative assessment showed a median distal resection margin of 10 mm (2-15 mm). In six patients, sufficient margins allowed for reconstruction while in two patients APR was needed. In three patients (37.5%), the pathological assessment changed the operative strategy: In one patient APR could be avoided while two patients required APR instead of the anticipated TME.

Conclusion: The intraoperative assessment of the TME specimen by an expert pathologist together with the surgeon is a valuable tool to avoid unnecessary APR or R1 resections. We therefore suggest routine intraoperative pathological assessment in all operations for borderline low rectal cancers.

Keywords: Abdominoperineal resection; Frozen sections; Low anterior resection; Rectal cancer; Resection margin; Total mesorectal excision.

MeSH terms

  • Abdomen / surgery*
  • Adult
  • Aged
  • Cohort Studies
  • Female
  • Humans
  • Intraoperative Care*
  • Male
  • Middle Aged
  • Pathologists*
  • Perineum / surgery*
  • Rectal Neoplasms / surgery*
  • Rectum / surgery*