A 58-year-old man is diagnosed with a rectal adenocarcinoma located 2 cm from the anal verge on digital rectal examination. MRI shows the tumor invades the external anal sphincter. There is no metastatic disease. What is the most appropriate surgical management?

• A Low anterior resection with coloanal anastomosis
• B Hartmann's procedure
• C Local excision via transanal endoscopic microsurgery (TEM)
• D Abdominoperineal resection (APR) with permanent colostomy ✓

Explanation

Tumors involving the external anal sphincter or levator muscles cannot be adequately resected with sphinctering surgery while achieving clear margins. Abdominoperineal resection with permanent end colostomy is the standard treatment. APR is also indicated for tumors less than 1 cm from the anal verge where adequate distal margin cannot be achieved. Local excision is only for early T1 tumors with favorable histology.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.