In the last three decades, surgical treatment of rectal cancer (RC) has been subjected to a deep revision. Many biological, pathological and technological innovations have contributed to these changes. Among these, the most important were: endorectal US and MRI for a more accurate preoperative staging and selection for conservative surgery, TME for a more radical local exeresis, minimally invasive surgery (laparoscopic, robotic, TEM) to enhance the quality of post-operative recovery, neoadjuvant therapy to increase the overall results of the multidisciplinary therapeutic approach.
At last, but not least, introduction of the enhanced recovery after surgery (ERAS) program or fast- track (FT) surgery, defined as a coordinated perioperative approach aimed at reducing surgical stress response, supporting organ functions, facilitating and optimizing recovery, offers a further opportunity to increase the quality of any surgical approach. These programs, initially introduced for colonic resections, are till now not sufficiently tested for RC exeresis.
The use of a stoma to protect colorectal anastomoses, particularly in low and ultralow resections, remains a controversial issue. Why and when a stoma should be performed and which stoma (ileo- or colostomy) is preferable are questions that remain unanswered.
Open resection of RC, which is currently the most widespread procedure, is increasingly regarded as an outdated technique, which could be less utilized in the near future.
Can an ERAS program enhance quality and reduce length of a post-operative period in open resections in order to minimize the difference compared with minimally invasive surgery, which seems to be a more expensive surgical procedure?
To answer to the above mentioned questions still open, we started a prospective protocol of surgical treatment of all rectal cancer based on the following principles: elective open resection, TME nerve sparing procedure, no primary stoma, FT program, neoadjuvant therapy (in T3 -T4 and/or N1 middle and low rectal cancers).
For FT program, exclusion criteria were: emergency surgery, ASA class IV, the need for a stoma, T4 tumor, the inability to provide informed consent, severe diabetes, documented slow gastrointestinal transit, abnormal coagulation. We modified the original protocol of FT surgery described by Kehlet et coll. for colonic resections adapting it to rectal cancer surgery. We prefer to maintain traditional oral preparation of the colon, a NGT is left in place for twelve hours, liquid oral feeding started twentyfour hours after surgery.
The aims of this study were to evaluate
1.The results, in terms of mortality, morbidity, quality and length of post-operative stay of elec tive open resections for all rectal cancers (including ultralow neoplasms and patients submitted to neoadjuvant therapy) without primary stoma and utilizing FT protocol,
2. How many patients required a secondary stoma,
3. The risks of omitting a primary stoma in terms of mortality and morbidity.
The results were compared to more extensive case series and meta-analysis of laparoscopic resections (LR) published in the last years.
We included in this study 76 consecutive patients who responded to the above mentioned criteria, all operated on by only one surgeon.
The extensive analysis of the results of this study is not yet been published.
The results obtained by us allowed some considerations:
1. Open resection of RC without primary stoma shows the same mortality and morbidity rates of the largest series of laparoscopic/robotic surgery. Utilizing FT protocol, the quality of postoperative period and the length of hospital stay were only less inferior to those reported with minimally invasive surgery. only less inferior to those reported with minimally invasive surgery.
2. Five patients (6,6%) required a stoma: 93,4% of all RC were treated without temporary stoma.
3.Omitting a primary stoma does not increase the incidence of major postoperative anastomotic leaks and the mortality rate.
However, the need to perform an urgent secondary stoma lengthens and deteriorates significantly the quality of postoperative stay.
The limited number of our patients does not allow us to draw definitive conclusions and only a multicentric prospective trial can answer to the important questions still open in surgical treatment of RC.
In conclusion, the issue of the use of a primary protective stoma and the FT protocol should be considered in evaluating the quality of the results obtained in patients surgically treated for RC.