Salvage rectal surgery: Overview

Recurrence of the disease represents the major problem in patients who undergo "curative" resection for rectal cancer, with published rate ranging from 3 to 50%. Most relapses occur within first two years of follow-up. Depending on the site of the recurrence, it can be local or distant. It also can be solitary or diffuse. In terms of potential surgical cure the best results are achieved with solitary, localized metastases. The most common sites of the solitary metastases are pelvis, liver and lung, with a fairly even distribution among these three sites. Other sites of the localized metastases can be peritoneum, lymph nodes, brain, bone, abdominal wall, ureter and kidney. These sites are less common, but not so amenable to resection. Local recurrence varies depending on the original type of surgery. It can be stated that surgical technique directly influences local recurrence rate in patients with rectal cancer. According to the results from a number of different authors 5-year survival rate after reresection is 2-13% of all patients with locally recurrent cancer, both alone and associated with distant metastases. The most important moment in this problem is to decide when not to operate. The absolute contraindications for salvage surgery are: "frozen pelvis", aneuploid tumors and those with mucinous component, clinical or CT evidence of invasion of the pelvic nerves, lymphatics or veins, or ureter bilaterally. Also, evidence of involvement of the lateral pelvic sidewalls and/or upper sacral marrow, and/or S2 is an absolute contraindication for surgery. Thus, main goals of this type of surgery are respectively: palliation of symptoms, a good quality of life and, if possible, cure with low treatment-related complication rates.