Keywords

The 2nd edition of this textbook is published 4 years after the first edition. During these years, there has been significant progress in the field of surgical treatment of rectal cancer. However, these achievements are built on the fascinating history of colorectal surgery since the paradigm shift in medicine that followed the great developments of science, technique and industrialization since the 1850s.

This history has been described in the most interesting way by our colleague, the late Professor Lars Påhlman. It is highly important knowledge for contemporary surgeons, as it is the key to put our current knowledge and practice into the necessary perspective to take new steps into the future of colorectal cancer surgery.

We deeply regret the far too early death of our highly estimated colleague Lars Påhlman. His legacy is based on his rich knowledge of the literature, tireless efforts to increase knowledge by new and relevant clinical research, and his generous personality. We therefore wish to honour Lars Påhlman and let the chapter “Introduction to surgery” to be an unchanged part of this textbook.

Since the first edition, a number of studies that were ongoing then have been published. The randomized controlled trials to compare laparoscopic versus open surgery for rectal cancer indicate that laparoscopy-assisted resection is likely to be equivalent to open surgery [1,2,3], albeit somewhat less clear as compared with laparoscopic colon resections [4]. The role of robot-assisted surgery for rectal cancer is currently less clear; and assessment of this technology may vary depending on the choice of outcome measures [5]. The analysis of the ROLARR trial highlighted the importance of the surgical learning curve [6]. The newest technique for treatment of rectal cancer, transanal total mesorectal excision (taTME), is currently studied by the COLOR III trial [7]; however, taTME appears to be more controversial than any of the other recent surgical developments [8]. Due to some reports of unfavourable outcomes, the procedure has recently come under increased scrutiny [9, 10]. Such controversies create the need for well-designed clinical trials. Moreover, surgeons will in the coming years have to acknowledge the importance of molecular aspects of cancer biology and develop comprehensive approaches to address the increasing number of elderly, frail and comorbid patients, or those with incurable disease who need treatment focusing on quality of life, guided by their personal wishes and expectations of remaining lifetime.

Lars Påhlman always underlined the importance of research in colorectal surgery, and it was one of Lars’ common sayings that every surgical department should participate in one or several ongoing trials at any time. We want to honour this commitment by adding a separate chapter on surgical research, which hopefully will contribute to increase the knowledge about and interest in surgical research.

1 From Miles to Heald and Further

With more than one million new cases yearly in the world, colorectal cancer (CRC) is one of the most frequent cancers, and approximately one-half of the patients will die from the disease [11]. The individual lifetime risk to achieve a CRC is 5% in developed and industrialized countries [12]. In Europe, it is the third most prevalent cancer and the second most important regarding cancer-specific mortality [13, 14]. Surgery has been and is still the only option to be cured for colorectal cancer, and the first report of a successful resection of a colonic cancer including an anastomosis was from Reynard of Lyon in 1833 [15]. However, the majority of patients had a palliative defunctioning colostomy only due to severe complications, but later a resection and double-barrel colostomy were used to achieve intestinal continuity. Successively more surgeons obtained experience with intestinal suture leading to an increasing number of colonic resections performed, but still the mortality for intra-abdominal resection and anastomosis was approximately 40% at the end of the nineteenth century due to problems with intra-abdominal leakage and sepsis [16].

The Danish surgeon, Bloch, in 1894, presented an idea of preventing intra-abdominal complications by introducing the concept of extraperitoneal resection and anastomosis, based upon two cases in which the loop of colon containing the carcinoma had been mobilized and brought out through the abdominal wall. Later, the same manoeuvre was also independently described by von Mikulicz of Breslau [17]. Paul of Liverpool also described a very similar manoeuvre (Paul, 1895), but in his operation, the protruding loop was excised at the time of exteriorization, and special large, right-angled glass tubes were tied into the lumina of the distal and proximal ends of the colon [18], a procedure which became known as the Paul–Mikulicz procedure (although Bloch’s name should have been added) and was popular throughout the world.

In rectal cancer, the limitation of radical surgery was more a matter of possibilities to survive why the earliest surgical approaches to carcinoma of the rectum were via the perineum by Faget (1739), Lisfranc (1826) and Verneuil (1873). Subsequently the technique was entirely extraperitoneal, but despite this approach, patients rarely survived the operation due to perineal sepsis locally or a locally non-radical procedure [19,20,21]. Not until Ernest Miles realized that cancer surgery is more a matter of resecting the lymph node than the bowel, the outcome started to change. Although his initial results were devastation due to postoperative mortality, his philosophy gained acceptance worldwide [18, 22]. Another technique to achieve cure but reduce mortality was an abdominal resection without an anastomosis proposed by Hartmann [23].

However, in the early days, limitations to radical surgery were more a matter of good anaesthesiology and postoperative pain control than surgery by itself. Not until appropriate anaesthesiology was available surgery could become more radical. Also with the new anastomotic technique, developed in the late nineteenth century, surgery became more reliable to all patients. During the first pass of the twentieth century, a major change in the treatment was seen, and surgery was rather standardized with limited segmental resection in colon cancer patients, and for rectal cancer patients, an abdominal perineal excision became standard of care after Earnest Miles’ data were presented as well as data from Henry Hartmann. After that, it ended up with stomas. The postoperative mortality was very high as well as the postoperative infection rates. During the last century, however, several things slowly changed making surgery more secure.

2 Mechanical Bowel Preparation

It was a non-disputed knowledge since the late nineteenth century that a better outcome was received if faeces were removed from the bowel. Several sophisticated techniques with mechanical preoperative bowel preparation have been used like salted water enema to per oral bowel preparation with polyethylene glycol or sodium phosphate. However, based upon experience in surgery for emergency cases, where resection has been more common, data from the 1980s and 1990s have proven that the outcome might be worse after mechanical bowel preparation for elective surgery. Two large randomized trials have now shown that bowel preparation should not be used in colonic surgery [24, 25]. The evidence is not that strong in rectal cancer surgery, but a lot of data support that surgery can be done safely without major bowel preparation even for rectal cancer surgery [26].

3 Antibiotic Prophylaxis

Before the era of antibiotics, more than 30% of the patients experienced wound infections. Once antibiotics were introduced, several methods of using antibiotics have been tested. In the beginning, both per oral and intravenous antibiotics were given to the patients postoperatively. During the 1960s and 1970s, randomized trials showed clear that preoperatively given antibiotics are better than administrated postoperatively. Moreover, the number of doses has been reduced to one dose preoperatively covering both aerobic and non-aerobic microbes. This is now standard of care, and only in emergency surgery with extremely contaminated wounds one could consider postoperative antibiotics too.

4 Thromboembolic Prophylaxis

It is well known that the risk of having a thromboembolic event is increased after major abdominal surgery for cancer. It increases even more if surgery is performed in the pelvis. Based upon knowledge from randomized trials in hip and knee surgery, new trials have been run showing that there is an increased risk of having deep vein thrombosis but also pulmonary embolism after colorectal cancer surgery if no prophylaxis is used. Subsequently the recommendation is to give some type of prophylaxis, and the most commonly used is un-fractionated heparins or equivalent treatment, and this should be ongoing at least 1 week and probably 1 month postoperatively. In cancer surgery of the large bowel, the dose has to be doubled [27].

5 Anastomotic Techniques

The classic anastomotic technique has for many years been a double- or triple-layer anastomosis with an inner row of adapting the mucosa and an outer row of adapting the serosa. In the late nineteenth century, there was an academic fight between Mikulicz and Billroth whether the mucosa in the anastomosis should be invaginated or not. It was not an evidence-based discussion but merely a matter of who was the strongest surgeon at that time. Billroth won, and since his time an invagination of the anastomosis by knitting serosa to serosa became standard of care. Until the last 25 years of the twentieth century, the most common sewed material was catgut and silk. At that time, staplers were introduced, both circular staplers for low rectal anastomoses but also staplers for colonic anastomoses. During the same time period, modern suture material like polyglycolic acid entered the market, and hand-sewn anastomoses with a single-layer interrupted or non-interrupted anastomosis technique were also introduced. Other techniques like compression anastomoses with metal ring (the Murphy button) or by a biodegradable material (Waltrac®) have also been used but not popularized. The latest type of anastomotic techniques is a compression anastomosis with the use of a memory-shaped Nitinol, a metal alloy that contains a nearly equal mixture of nickel and titanium. This technique is still under investigation.

The most common technique is either hand-sewn or stapled anastomosis, and several randomized trials have shown that stapled anastomoses are as good as hand-sewn anastomoses, and it is nowadays the preference for surgeons to use either technique.

6 Important Steps in Modern Rectal Cancer Surgery

In the beginning, rectal cancer surgery was performed with a posterior approach, mainly due to the problem with anaesthesia. Once anaesthesiologists were able to take care of the patients, more advanced surgery could be done. Ernest Miles observed a very high local recurrence rate and therefore proposed an abdominal approach to be able to take care of the lymph nodes. In his initial experience with an abdominoperineal excision, the mortality was high for the first time patients could be cured [22]. Henry Hartmann, a French surgeon, also introduced an abdominal resection of the rectum, i.e. the tumour bearing part of the rectum was resected, the distal rectal stump closed and a sigmoidostomy was performed [23]. This became popular since mortality could be kept on an acceptable level. In the 1930s, Dixon proposed that low-situated sigmoid cancer and recto-sigmoid tumours could be treated with an anastomosis instead of a stoma [28]. Dixon has been claimed to be the father of anterior resection. However, a very low anterior resection and sphincter-sparing procedure were not introduced until the stapler device appeared on the market in the late 1970s. Once sphincter-preserving surgery became more common, there was a debate about the safety and length of the distal margin, and for many years, the distal margin should be at least 5 cm, based upon anatomical and pathological studies.

When the results were analysed, data on unacceptable high local recurrence rates became more obvious, with reports on recurrence rates of 50% [29]. Moreover, reports indicated the importance of the operating surgeon [30] and more attention to the circumferential resection margin than the distal margin [31]. With the knowledge of the local recurrence and not only the radicality in the distal margin but also in the lateral margin, it was obvious in the early 1980s that the majority of the local recurrences could be prevented with surgery alone. However, already at that time adjuvant and neoadjuvant radiotherapy had started to be used, and in several countries radiotherapy was thought to be the solution (see Chap. 12).

At the same time as radiotherapy was popularized, reports from single centres showed very good results without radiotherapy [32,33,34]. Professor Bill Heald introduced the whole concept of total mesorectal excision, (TME) [35]. In that concept, a dissection following the embryological planes with a radical circumferential resection margin was as important as the distal margin. With the knowledge that the distal margin in very low rectal cancer could be as short as 1 cm, the proportion of sphincter-preserving procedure increased, and in devoted centres, 80% will not have a sigmoidostomy [36]. With the introduction of TME, the local recurrence rate continued to decrease, and national training programmes were launched resulting in a dramatic change in the local recurrence rates below 10% with subsequent survival benefits [37,38,39].

In one group of the patients, i.e. those having an abdominoperineal resection (APR), the local recurrence rate was still very high mainly due to a non-radical excision with a positive circumferential resection margin. With the introduction of a more cylindrical excision of the levator area when an APR is performed, the coning into the tumour area is prevented. With this technique, the local recurrence rate after an APR has been reduced [40]. To achieve a specimen with negative resection margins, it is important to stop the abdominal phase at the level of cervix or vesicles and start to operate from below and follow the pelvic floor laterally and divide the pelvic floor together with the specimen making a good cylindrical excision.

7 Important Steps in Modern Colon Cancer Surgery

An important consideration in colon cancer surgery is the distance from the tumour to the resection margin. The rational is to excise lymph nodes along the bowel which can be metastatic. Japanese data have shown that 10 cm from the tumour is a safe margin, since tumour deposits rarely are found more laterally from the primary tumour [41, 42]. The same philosophy as for rectal cancer, i.e. following the anatomical and embryological planes, can also be applied on colon cancer surgery, too. Very little attention to the colonic anatomy has been paid, but very recent data from the Erlangen group have emphasized its importance and have also presented very good results [43]. Still it is too early to evaluate this philosophy, but based upon the dramatic change in rectal cancer surgery, this will probably also change colon cancer surgery to the same extent.

8 Training Organization

Based upon the national quality register, it is obvious that surgery can be improved. The experience from rectal cancer registries from the Scandinavian countries showed that surgeons can train and learn better [37,38,39]. Likewise, the experience from The Netherlands, where surgeons were taught to do a proper TME before they included patients in the Dutch radiotherapy trial, could demontrate an improvement. The training program in rectal cancer surgery run in Stockholm area, Sweden, has also shown that training is important [44].

Concentration of surgery to fewer centres with more devoted surgeons has also been proposed, although the individual surgeon is more important than the “unit” [45]. To create a good milieu for surgery, most centres with good results propose two consultant surgeons operating together making the rectal cancer procedure quick and easy and possible to learn from each other. This has become the tradition in the Scandinavian countries, and by doing so the results have improved steadily. To follow the process auditing, the results are essential.

9 Laparoscopic Surgery

The first laparoscopic bowel procedure was performed in 1991. Very soon afterwards, several reports on feasibility of laparoscopic surgery for cancer were presented. However, the whole idea of laparoscopic colonic resection for cancer was stopped due to several reports of port-site recurrences [46]. It was difficult to understand why a recurrence appeared at the site of the ports. Hypotheses like the “chimney effect”, contaminated instruments, creating a tumour cells aerosol and adherence of disseminated cancer cells to different materials were tested experimentally. Unfortunately, all data ended up with a rather simple knowledge that most reasons for having port-site metastases were a matter of bad surgical technique traumatizing the tumour during instrumentation.

Due to the uncertainty of the rationale of laparoscopic bowel resection for cancer, several randomized trials were started, and all of them showed that, in selected patients, no difference in cancer specific or overall survival could be demonstrated [47,48,49,50]. A meta-analysis of these four trials could not demonstrate any difference in outcome, stage by stage [51]. However, one has to remember that there were selections to these trials, and several patients are still not suitable to laparoscopic resection, like T4 tumours growing into other organs. The laparoscopic technique has demonstrated several advantages: less complications, shorter length of stay and quicker return to daily living and work. The laparoscopic technique has illustrated the importance of early discharge, and with an enhanced recovery program to patients having open surgery, a similar effect can be reached.

For rectal cancer, the evidence is not that strong. There are several hospital reports indicating that the results are as good as with open surgery [52, 53]. In one of the randomised trials, rectal cancer was included [50], but the numbers were few and the evidence is not clear regarding laparoscopic surgery for rectal cancer. At least three ongoing trials will answer this question.

Although laparoscopic surgery for both colon and rectal cancer is growing, not more than 60% in dedicated centres will have a laparoscopic procedure. On national level in the majority of countries, less than 10% of all patients will undergo a laparoscopic procedure. Probably this frequency will increase steadily over the years.

10 Robotic Surgery

The introduction of robotic surgery has given a new dimension in colorectal cancer surgery. It has been tested in the lesser pelvis treating prostate cancer and has later been used for rectal cancer surgery. It is an expensive tool, but those having learned the technique have stated that the precision in dissection is much better than laparoscopy, mainly due the degree of freedom how the instruments can be used. Still there are no randomized trails showing any benefit, but those are ongoing. The most important advantage is dissection in an obese patient with a narrow pelvis [54].

11 Surgery Is Not Just Operation: It Is Academic

During the last two decades, evidence-based medicine has become more and more important. Lots of dogmas in colorectal cancer surgery have slowly been changed, but this change has only been possible due to good evidence. The best way to challenge dogmas is of course using randomized trials.

Changes we have seen over the years, based upon randomized trials, are that the drainage will increase anastomotic leakage and should therefore be used selectively. We have also learned that the mechanical bowel preparation will increase morbidity postoperatively, is not well tolerated and should only be used when it is necessary, like finding polyps with a preoperative colonoscopy or other very specific reasons. Enhanced recovery programs have also been evaluated in randomized trials, and based upon those data, the fast-track idea has become standard of care in most patients with colorectal cancer. The use of prophylactic antibiotics has been changed, based upon randomized trials, from postoperative to preoperative administration and shorter treatment time. Other important changes, studied in large randomized trials, are the use of thromboembolic prophylaxis.

In this way, with randomized trials, surgery has slowly been changed, and by moving forward, step by step, a new hypothesis has been tested rejecting some old-fashioned dogmas. This is the way surgery will improve. However, once the evidence is available, it has been shown that it takes up to 10–15 years until the majority (more than 95%) of the hospitals have adopted the evidence according to literature and implemented in the practice.