Surgery for Colorectal Cancer - Trends, Developments, and Future Perspectives

Abstract

Background: Although colorectal surgery is long established as the mainstay treatment for colon cancer, certain topics regarding technical fine-tuning to increase postsurgical recurrence-free survival have remained a matter of debate throughout the past years. These include complete mesocolic excision (CME), treatment strategies for metastatic disease, significance of hyperthermic intraperitoneal chemotherapy (HIPEC), and surgical techniques for the treatment of colorectal cancer recurrence. In addition, new surgical techniques have been introduced in oncologic colorectal surgery, and their potential to provide sufficiently radical resection has yet to be proven.

Methods: A structured review of the literature was performed to identify the current state of the art with regard to the mentioned key issues in colorectal surgery.

Results: This article provides a comprehensive review of the current literature addressing the above-mentioned current challenges in colorectal surgery. The focus lies on the impact of CME and, in relation to this, on lymph node dissection, as well as on treatment of metastatic disease including peritoneal spread, and finally on the treatment of recurrent disease.

Conclusion: Uniformly, the current literature reveals that surgery aiming at complete malignancy elimination within multimodal treatment approaches represents the fundamental quantum leap for the achievement of long-term tumor-free survival.

Keywords: Advanced cancer stage; Colorectal cancer; Complete mesocolic resection; Hyperthermic intraperitoneal chemotherapy, HIPEC; Resection; Surgical treatment.

Fig. 1

Current data regarding developments in CRC-related hospital cases and mortality.

Fig. 2

a Schematic illustration of the anatomic plane for complete mesocolic excision (CME) in right-sided hemicolectomy. b Crucial intraoperative step for CME in right-sided hemicolectomy. Mesocolon and mesoileum have to be mobilized along Toldt's fascia to the duodenum and lower edge of the pancreas. The vascular trunks of the middle (transverse) colon and ileal artery/vein are the dissection margins to the left. c Crucial intraoperative step for CME in sigmoid resection hemicolectomy. The inferior mesenteric vein should be divided at the lower edge of the pancreas (triangles); the left superior marginal vein may be preserved for improved venous drainage of the relocated descending colon and left colic flexure. Note that the pancreas is still covered by the mesenteric section of the transverse colon.

Fig. 3

Images of a 77-year-old man presenting with a second local recurrence of a rectal carcinoma. He was treated with sacropelvic excision and formation of a descendostoma plus ileum conduit with urostoma following repeated radiation therapy and chemotherapy.