When a person is diagnosed with rectal cancer that is near the anal opening, our priorities must be in order. Naturally, nobody desires to live with a permanent stoma (a bag attached to the abdomen for the passage of faeces). When there is little distance of the tumour from the anal sphincters, which control the passage of stool and flatus, in many instances the surgical option given entails a permanent colostomy.

So how does one deal with this situation? Firstly, almost all patient will require chemoradiation before surgery in this situation. This may increase the chance of sphincter preservation. Also, laparoscopic or minimally invasive surgery is usually equally effective in saving the passage, with the additional advantage of lesser scar and pain. Also, expertise for sphincter saving procedures varies from center to center. So, we must be sure that the facilities are available. Lastly, without surgery, cure is highly unlikely unless the cancer is a squamous carcinoma and not an adenocarcinoma, in which case chemoradiation may be sufficient.

Let us prioritize our perspectives:

1. 1. 1. Safety – There should be no compromise on safety while taking decisions and risks should be minimized
      2. Complete tumour removal – unless the tumour is removed 100% there is no point in carrying out an operation since the disease is sure to return; neither at the cost of sacrificing the passage, nor removal or partial removal of adjacent organs
      3. Sphincter preservation – if the above two criteria are fulfilled and there is a reasonable chance that the tone/control will be preserved, this is possible through an ultralow anterior resection or intersphincteric resection
      4. Minimally invasive surgery – when dealing with cancer, laparoscopic or robotic surgery are good options if the above priorities have been fulfilled, but not at the cost of any of the above

In conclusion, saving the anal passage is possible is many situations and the option should be explored. But at other times, the best quality of life is achieved by living with a permanent stoma.

The best, and usually only, chance of cure in colorectal cancer is surgery. Minimally invasive (keyhole) surgery includes laparoscopic and robotic surgery techniques which have shown to be beneficial for patients in terms of faster recovery after the operation. There remains a certain fear that such minimally invasive surgical options may not be as good as conventional open surgery for cancer removal.
There is now sufficient scientific evidence to support minimally invasive surgery for cancer, especially colorectal cancer. That means that the outcomes/survival of patients is similar if the surgery is performed with a large incision or through keyhole incisions. The lesser pain and faster discharge with quicker return to routine activity are additional advantages of keyhole surgery. Having said this, there are still certain colorectal cancers that even the most adapt laparoscopic cancer surgeons would still prefer to perform using conventional techniques. This can be left to the discretion of the treating oncologist.
In short, the vast majority of patients need not fear laparoscopic surgery for colorectal cancers and, in fact, will fare better and heal sooner with this technique. The opinion of the treating surgeon should be respected, and any concerns can be easily dealt with by the treating oncologist.

Neuroendocrine Tumours (NETs) have featured in the news quite frequently in recent times. This is partly due to various celebrities being diagnosed and sometimes succumbing to this disease. People like Steve Jobs, Aretha Franklin, and the actor Irrfan Khan, closer to home. The natural tendency is to assume that this disease is primarily related to the brain. Not many realize that this is mainly an abdominal disease which tends to mimic cancer. Although it is a rare tumor, the incidence seems to be increasing, even our country.

NETs mainly affect the abdominal organs such as pancreas, intestine, appendix, stomach, as well as other organs. It can also affect the lungs and other organs as well. Many NETs are detected unexpectedly at regular check-ups or while investigating for something else.

The good news is that most NETs do not behave like typical cancers. The low-grade NETs (grade 1 and 2) are slow growing tumours which have high cure rates. There are also many treatment options which are well tolerated by patients. Some NETs are functional, which means there are hormones secreted by the tumour into the blood stream causing symptoms related to that hormone. For example, if insulin is secreted, then the blood sugar tends to get extremely low, causing giddiness. Unfortunately, high grade NETs (grade 3) tend to behave like cancers, and generally require chemotherapy.

NETs usually require a special PET scan called a 68-Gallium PET scan or a DOTA-TOC scan. This helps to identify the tumour and its spread. The treatment is usually surgical. Other options like targeted therapy, long acting octreotide, peptide therapy, and others are also effective.

To summarize, NETs are a relatively rare group of tumours which are usually ‘well-behaved’, with numerous treatment options, the primary modality being surgery.