Restorative proctectomy and colonic reservoirs

Abstract

Restorative proctectomy has gained international popularity and global acceptance for the treatment of rectal cancer as an alternative to abdominal perineal resection (APR). A restorative procedure allows for the maintenance of intestinal continuity and thus the normal evacuatory pathway. Restorative proctectomy has been made feasible through the development of better surgical instruments, linear and circular staplers, and a better understanding of rectal cancer oncology. The principles of total mesorectal excision allow for proper resection of rectal cancer, respecting the mesorectal envelope and ensuring adequate circumferential (radial; lateral) and distal margins, without negating the ability to provide most patients with rectal cancer with a restorative yet also curative surgical option. When rectal cancer is treated by surgeons with expertise in rectal surgery, the rates of restorative procedures are higher, rates of permanent stoma lower, and rates of survival higher. These findings highlight the importance of extensive knowledge of the various restorative options and indications for surgeons treating rectal cancer. In the setting of distal third rectal cancers, pre-operative planning and intra-operative decision making becomes even more crucial in selecting those patients who require an APR and those who may undergo a restorative proctectomy.