Total mesorectal excision: the unrecognized pelvic plane

Oncological outcome of wide anatomic resection with partial mesorectal excision in patients with upper and middle rectal cancer

AIM

The aim was to investigate the influence of distal resection margin and extent of mesorectal excision on long-term oncological outcomes.

METHOD

Consecutive patients with upper and middle third rectal cancer from June 2006 to February 2016 were reviewed. Patients were divided into four groups depending on the distal margin considered as a surrogate marker of the extension of mesorectal excision (Q1 ≤10 mm, Q2 11-20 mm, Q3 21-30 mm, Q4 ≥31 mm). Local-recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS) were estimated. Cox regression models were used to investigate the influence of surgical and clinicopathological variables on prognosis by adjusting for confounding factors.

RESULTS

Two hundred and eleven patients with mid (125) and upper (86) rectal cancer underwent wide mesorectal excision. The median follow-up was 48.64 months (interquartile range 28-63). 17.5% patients developed recurrence. The 5-year LRFS, DFS and OS for all patients were 93.20%, 83.89% and 80.1%, respectively, with no statistically significant differences between groups (LRFS, P = 0.601; DFS, P = 0.487; OS, P = 0.468). In the multivariable analysis the recurrences and survival were associated with the quality of the mesorectum (LRFS, hazard ratio 10.629, 95% CI 2.324-48.610, P = 0.002; DFS, hazard ratio 2.789, 95% CI 1.314-5.922, P = 0.008).

CONCLUSION

A wide anatomical resection with partial mesorectal excision and shorter distal resection margin does not jeopardize the oncological outcomes.

Reconstruction of large perineal defects after advanced malignant tumour resection: a simple gluteal thigh flap modification

Reconstruction of large defects in the perineal region, after resection of advanced malignant tumours is challenging because both coverage of the perineal skin defect and adequate filling of the pelvic space must be achieved simultaneously. This manuscript introduces a simple gluteal posterior thigh flap modification for the reconstruction of such defects. A trilobed flap, in the gluteal and posterior thigh regions, was designed to be of an adequate size to repair the dermal and pelvic floor defects. After the flap was elevated and rotated 90^°, the posterior thigh portion was denuded. The lateral portion of the deep gluteal fascia was incised to allow medial advancement. Thus, the flap could be easily moved to fill the defect, without tension. To evaluate the results, we reviewed 8 patients with large (>10 cm in diameter) advanced perineal carcinomas. For each patient, the defect was successfully reconstructed using the technique described. A secondary operation was required for one patient, due to atheromatosis that developed several months after the operation. Another patient developed donor site wound dehiscence and was treated with skin grafting. The described technique facilitates the effective reconstruction of large perineal defects.

Four-arm single docking full robotic surgery for low rectal cancer: technique standardization

The authors present the four-arm single docking full robotic surgery to treat low rectal cancer. The eight main operative steps are: 1- patient positioning; 2- trocars set-up and robot docking; 3- sigmoid colon, left colon and splenic flexure mobilization (lateral-to-medial approach); 4-Inferior mesenteric artery and vein ligation (medial-to-lateral approach); 5- total mesorectum excision and preservation of hypogastric and pelvic autonomic nerves (sacral dissection, lateral dissection, pelvic dissection); 6- division of the rectum using an endo roticulator stapler for the laparoscopic performance of a double-stapled coloanal anastomosis (type I tumor); 7- intersphincteric resection, extraction of the specimen through the anus and lateral-to-end hand sewn coloanal anastomosis (type II tumor); 8- cylindric abdominoperineal resection, with transabdominal section of the levator muscles (type IV tumor). The techniques employed were safe and have presented low rates of complication and no mortality.

Ultra-low anterior resection for low rectal cancer: five key tips to make it easy

The primary treatment for rectal cancer is still surgery. Surgery however, may be either preceded or followed by chemotherapy and radiotherapy as and when needed. Good surgery on its own when applied appropriately is associated with a very low rate of local recurrence. Bad surgery however, is associated with a high risk of local and systemic recurrence. The well-performed ultra-low anterior resection with total mesorectal clearance has been shown to be the most important step in the treatment of a low rectal cancer. The author details five key tips to make the performance of an ultra-low anterior resection easy. These five key tips are: tip 1 Decide on the best approach for your particular patient before surgery; tip 2 The inferior mesenteric artery is crucial in obtaining the right dissection plane; tip 3 The sigmoid colon should be used for construction of the J-pouch whenever possible; tip 4 Use of a good light source is the key to obtaining a good idea of where to operate and to keeping to the right planes; tip 5 The last key to making surgery easier is to have a good head and good hands. Surgeons must know precisely the reasons why they do what they do in the way they do. Surgery which is difficult may be expected to carry with it more risks and therefore poorer results. Surgery which goes smoothly and is easy is usually rewarded with good results. Surgeons should try to make their surgery easier and the tips offered here are steps that will do this.

New laparoscopic double-stapling technique

BACKGROUND

Laparoscopic surgery for colon cancer has been shown by several randomized, controlled trials to be an acceptable alternative to open surgery; however, laparoscopic rectal surgery has not been evaluated in a randomized trial. One of the most serious problems associated with laparoscopic rectal surgery are bowel clamping, irrigation, and transection of the rectum, and laparoscopic rectal surgery has not been as reliable as open rectal surgery.

MATERIALS AND METHODS

We present our new technique, the laparoscopic double-stapling technique, which eliminates these problems. This technique uses curved Doyen forceps introduced through the wound just above pubis symphysis for clamping the rectal wall at the anal side of the tumor. An endolinear stapler (length 60 mm) is inserted through the same wound, applied at the rectal wall parallel and caudal to the Doyen forceps, and transects the rectum under pneumoperitoneum. We used this technique for eight cases of rectal surgery.

RESULTS AND DISCUSSION

The laparoscopic double-stapling technique provided secure bowel clamping and rectal irrigation. The number of cartridges used in laparoscopic double-stapling technique cases was not more than 2, with an average of 1.6 per patient. None of the laparoscopic double-stapling technique cases experienced major complications.

CONCLUSION

We consider that many cases of rectal cancer that are suitable for laparoscopic low anterior resection can undergo laparoscopic surgery by using this technique, which will improve the quality of rectal surgery.

Outcomes for abdominoperineal resections are not worse than those of anterior resections

PURPOSE

Local recurrence and cure rates following abdominoperineal resections have been reported to be much worse than sphincter-preserving anterior resections. We compared the oncologic outcomes of patients treated by abdominoperineal resections with those following sphincter-preserving anterior resections.

METHODS

The medical records of patients who underwent radical rectal resection for rectal carcinoma at the Colorectal Surgery Department, Singapore General Hospital, during the period from April 1989 to April 2002 were reviewed. A total of 791 cases were studied. Operative procedures were classified as either abdominoperineal resections or anterior resections with either straight or pouch anastomosis. Total mesorectal excision was routinely performed for carcinomas of the lower middle and lower third of the rectum. Sentinel events, including local and systemic recurrences or morbidity and mortality, were tracked prospectively.

RESULTS

There were a total of 93 abdominoperineal resections (12.1 percent), 547 anterior resections with straight anastomoses (71 percent), and 130 anterior resections with pouch anastomoses (16.9 percent). Postoperative mortality was 2.6 percent and postoperative morbidity was 13.6 percent with an overall anastomotic leakage rate of 2.5 percent. The cumulative five-year local recurrence rate was 5.4 percent for abdominoperineal resections, 3.6 percent for anterior resections with straight anastomoses, and 3.8 percent for anterior resections with pouch anastomoses (P = 0.73 by log-rank test). The median time to local recurrence also did not differ significantly between the different procedures (abdominoperineal resections, 17 months, anterior resections with straight anastomoses, 18 months, anterior resections with pouch anastomoses, 13 months). Independent predictors for local recurrence included advanced tumor stage, tumor depth, and poorly differentiated tumors. The five-year cancer-specific survival was 70 percent. The type of anastomosis did not influence disease-free survival with median disease-free survival for patients who underwent abdominoperineal resections being 100 months, survival of anterior resections with straight anastomoses being 135 months, and survival of anterior resections with pouch anastomoses being 121 months (P = 0.33 by log-rank test). The independent factors for poor survival were age greater than 65 years, advanced tumor stage, tumor depth, and poorly differentiated tumors.

CONCLUSION

Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections.