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The American Society of Colon and Rectal Surgeons Clinical Practice CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of 09/29/2020 on C33fy907TbIFyHx640yafcu/EMfLBj0ena7lfLfVXefdPtD2mEHxq/BpP2kvObheZQ/k1t9qDSwPpsO8GTaUdiwuQjK1pQWMNN68JzRBGSAL9MK1M9Zl+7sUEot+0vYm+Up9l3OtRZ4= by http://journals.lww.com/dcrjournal from Downloaded Rectal Cancer Downloaded Y. Nancy You, M.D., M.H.Sc.1 • Karin M. Hardiman, M.D.2 • Andrea Bafford, M.D.3 from 4 5 6 http://journals.lww.com/dcrjournal Vitaliy Poylin, M.D. • Todd D. Francone, M.D., M.P.H. • Kurt Davis, M.D. Ian M. Paquette, M.D.7 • Scott R. Steele, M.D., M.B.A.8 • Daniel L. Feingold, M.D.9 On Behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons by C33fy907TbIFyHx640yafcu/EMfLBj0ena7lfLfVXefdPtD2mEHxq/BpP2kvObheZQ/k1t9qDSwPpsO8GTaUdiwuQjK1pQWMNN68JzRBGSAL9MK1M9Zl+7sUEot+0vYm+Up9l3OtRZ4= 1 Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas 2 University of Alabama at Birmingham, Birmingham, Alabama 3 Department of Surgery, University of Maryland, Baltimore, Maryland 4 Gastrointestinal Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois 5 Department of Surgery, Tufts University Medical School. Boston, Massachusetts 6 Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana 7 Department of Surgery, University of Cincinnati, Cincinnati, Ohio 8 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio 9 Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey he American Society of Colon and Rectal Surgeons cific procedure must be made by the physician in light of (ASCRS) is dedicated to ensuring high-quality pa- all the circumstances presented by the individual patient. Ttient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is STATEMENT OF THE PROBLEM composed of society members who are chosen because they Colorectal cancer remains the third most common cancer for have demonstrated expertise in the specialty of colon and both men and women, and the second leading cause of can- rectal surgery. This committee was created to lead interna- cer-related deaths in the United States annually. It is projected tional efforts in defining quality care for conditions related that 145,600 new colorectal cancer cases will have been diag- to the colon, rectum, and anus and to develop clinical prac- nosed and an estimated 51,020 deaths from colorectal cancer 1 tice guidelines based on the best available evidence. Although will have occurred in 2019. It is difficult to estimate statistics attributable specifically to rectal cancer because, historically, they are not proscriptive, these guidelines provide informa- much of the reporting for rectal cancer has been combined tion on which decisions can be made and do not dictate a with colon cancer as the single disease entity of “colorectal specific form of treatment. These guidelines are intended for cancer.”1 Overall, the incidence of colorectal cancer has de- the use of all practitioners, health care workers, and patients clined over the past decades, largely because of risk factor who desire information about the management of the condi- modification and screening.2 However, the 18- to 50-year age on tions addressed by the topics covered in these guidelines. group represents a unique cohort of patients in whom the 09/29/2020 These guidelines should not be deemed inclusive of all incidence of rectal cancer has been increasing. In contrast to proper methods of care nor exclusive of methods of care overall trends, rectal cancer incidence increased by 1.8% an- reasonably directed toward obtaining the same results. nually in younger adults between 1990 and 2013.1 The ultimate judgment regarding the propriety of any spe- In an effort to ensure that patients with rectal can- cer receive appropriate care using a multidisciplinary approach, the ASCRS collaborated with a multispecialty Earn Continuing Education (CME) credit online at cme.lww.com. This TM effort to develop the National Accreditation Program in activity has been approved for AMA PRA Category I credit. Rectal Cancer to create educational modules and a set Dis Colon Rectum 2020; 63: 1191–1222 of clinical standards focusing on program management, DOI: 10.1097/DCR.0000000000001762 clinical services, and quality improvement regarding rec- © The ASCRS 2020 tal cancer.3,4 Because rectal cancer management involves DISEASES OF THE COLON & RECTUM VOLUME 63: 9 (2020) 1191 Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. 1192 YOU ET AL: MANAGEMENT OF RECTAL CANCER multiple disciplines working in conjunction with one Defining the Rectum another, the surgical guidelines presented here must be The lower limit of the rectum is usually defined by the ano- viewed within that context and represent only a portion rectal ring, an anatomic landmark palpable on physical ex- of the treatment necessary for the optimal care of patients amination or visible radiographically as the upper border with rectal cancer. Colorectal cancer screening, bowel of the anal sphincter and puborectalis muscles.11 The upper preparation, enhanced recovery pathways, surveillance af- limit of the rectum has been variably defined by the splay- ter curative treatment, and prevention of thromboembolic ing of the teniae coli, the sacral promontory, the proximal disease, while relevant to the management of patients with valve of Houston, or the level of the peritoneal reflection. rectal cancer, are beyond of the scope of these guidelines A recent consensus conference defined the point of the sig- and are addressed in other guidelines.5–9 A guideline fo- moid take-off (ie, the junction of the sigmoid mesocolon cusing on colorectal surgery and frailty is forthcoming. and mesorectum) as seen on cross-sectional imaging as the upper limit of the rectum.12 Given that the correlation a- mong these landmarks is imperfect and the presence of all METHODOLOGY 3 valves of Houston is inconsistent, the upper limit of the These guidelines are based on the last set of ASCRS Practice rectum, from a clinical perspective, can be somewhat elu- Parameters for the Management of Rectal Cancer published sive. In practice, the location of a rectal cancer is most com- in 2013.10 A systematic search of MEDLINE, PubMed, Em- monly assessed by the distance from its distal margin to base, and the Cochrane Database of Collected Reviews was the anal verge, defined as the beginning of the hair-bearing performed from January 1, 2013 through January 15, 2020. skin. Tumors within 15 cm of the anal verge are typically Individual literature searches were conducted for each of classified as rectal cancers, although the total length of the 11 the different sections of the guideline (Fig. 1). An addi- rectum can vary by body habitus and sex. tional limitation to core clinical journals was applied if the initial word combination search returned more than 500 PREOPERATIVE ASSESSMENT articles. Directed searches using embedded references from primary articles were performed in selected circumstances. Evaluation The 1812 screened articles were evaluated for their level of 1. A cancer-specific history should be obtained eliciting evidence, favoring clinical trials, meta-analysis/systematic disease-specific symptoms, associated symptoms, family reviews, comparative studies, and large registry retrospec- history, and perioperative medical risk. Routine labora- tive studies over single institutional series, retrospective tory values, including CEA level, should also be evalu- reviews, and peer-reviewed, observational studies. Addi- ated, as indicated. Grade of recommendation: Strong rec- tional references identified through embedded references ommendation based on moderate-quality evidence, 1B. and other sources as well as practice guidelines or consen- sus statements from relevant societies were also reviewed. A cancer-specific history remains a cornerstone of the pre- A final list of 361 sources was evaluated for methodologic operative evaluation. Bleeding, pain, or symptoms related quality, the evidence base was examined, and a treatment to obstruction should be assessed to help determine the guideline was formulated by the subcommittee for this urgency and sequence of evaluation and intervention; this guideline. The final grade of recommendation and level consideration is particularly relevant when neoadjuvant of evidence for each statement were determined using the therapy is being considered. Urinary, sexual, and bowel Grades of Recommendation, Assessment, Development, function should be reviewed and symptoms indicative of and Evaluation system (Table 1). When agreement was in- malignant fistulas or severe radiating pain may alert the complete regarding the evidence base or treatment guide- surgeon to locally advanced disease involving adjacent pel- line, consensus from the committee chair, vice chair, and 2 vic organs. The patient’s medical fitness to undergo multi- assigned reviewers determined the outcome. Members of modality treatment should be assessed to guide treatment the ASCRS Clinical Practice Guidelines Committee worked planning and perioperative management. A thorough dis- in joint production of these guidelines from inception to cussion of perioperative risk stratification is beyond the final publication.
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