Pathological evidence in support of total mesorectal excision in the management of rectal cancer

BACKGROUND

Pelvic recurrence following conventional rectal resection for cancer is common. Preoperative iradiation has been shown in prospective randomized studies to halve this risk.

AIM

This multiinstitutional study aimed to assess the necesity of total mesorectal excision in rectal cancer.

PATIENTS AND METHOD

Pathological resections from 50 consecutive patients with adenocarcinoma of the rectum within 12 cm of the anal verge who underwent currative resection incorporating total mesorectal excision were examined. The resection specimen was examined by one of two pathologists. Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Some 38 had total mesorectal excision as a component of a low anterior resection and 12 with abdomino-perineal resection. "Cure" was defined as absence of metastatic disease and the excision of entire macroscopic tumor tissue with negative proximal and distal borders. TME was performed as described by Heald et al. The mesorectum was evaluated for lymph nodes and tumor deposists in three areas: deep to the tumor, in the proximal mesorectum and in the distal mesorectum.

RESULTS

Six patients had Dukes A lesions. Of 21 patients with Dukes B tumors, five had discrete foci of adenocarcinoma in the mesorectum, with no evidence of lymph node metastasis. Dukes C lesions were more heterogeneous, but 12 out of 23 patients had distinct mesorectal deposists in addition to mesorectal node involvement. Circumferential margin involvement was rare, but mesorectal tumor deposits were present in 17 of 44 patients with pT3 tumors, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumor had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure.

CONCLUSION

Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.

Preoperative ultrasonography as a mean of predicting the conversion of mini cholecystectomy into classic cholecystectomy

Cholecystectomy is considered to be the treatment of choice in symptomatic biliary lithiasis. Lately, due to medical progress, classic cholecystectomy has been gradually replaced by laparoscopic cholecystectomy and by mini cholecystectomy. Therefore, it is very important to determine certain preoperative factors which might predict the conversion of mini cholecystectomy (MC) into classic cholecystectomy (CC).

MATERIAL AND METHOD

The possibility of selecting high-risk conversion patients has important clinical implications, both for the surgeon and for the patient. Differentiating preoperative risk allows the surgeon to inform the patient about a high conversion risk to CC, and about the ensuing consequences: longer hospitalization period, longer postoperative recovery, greater costs. All the patients were examined by ultrasonography. The tests recorded six parameters: the diameter of the biliary duct (mm), the number of calculi, the diameter of the largest calculus (mm), the contracted aspect of the gallbladder, the distance between the tegument and the gallbladder fundus (cm), the distance between the tegument and the cystic duct (cm). All the variables were introduced into an initial model, which was checked using the colinearity method and significant observations, and subsequently reduced by eliminating insignificant predictive factors, revealed by Wald tests.

RESULTS

The significant predictive conversion factors to CC, quantified on the basis of regression analysis, are: age > 70, calculus with a diameter > 20 mm, biliary duct with a diameter > 6 mm, contracted gallbladder, distance between the tegument and gallbladder fundus > 7.2 cm, distance between the tegument and cystic duct > 17.1 cm.

CONCLUSION

Being a procedure that can be carried out on an outpatient basis and with rather low costs, ultrasonography plays a very important role in the preoperative prediction of converting MC to CC.

[Observations regarding lymphatic gastric drainage in malignant gastric pathology through intra-operatory lymphography]

The authors became interested in the lymphatic drainage of the stomach in order to attempt to determine for each region the type of drainage and the risk of cancer spread. They studied 50 dissection, including the stomach, 115 cases records of gastric carcinoma, 8 lymphographies by ultrafluid lipiodal, and 48 preoperative injections of vital colorant. The system of drainage proposed by Rouvière was on the whole confirmed; however, one should emphasize the doubling of the hepatic chain, the existence of long collectors which bypass a relay in the left gastric artery, the importance of the posterior gastric artery which transmits the lymphatic of the splenic chain. Finally, the authors emphasize the existence of 3 longitudinal areas on the stomach where the presence or absence of valvules in the subserous collectors orients the lymph towards the lesser or greater curvature of the stomach, which easily explains the onset of isolated carcinomatous adenopathy, situated on the curvature opposite the neoplasm.

[The diagnostic strategy in abdominal trauma]

Diagnosis of a deep visceral lesion in an adult following abdominal contusion is almost always difficult as the abdominal signs are later or masked by associated lesions. All of the controlled studies agree on the superiority of peritoneal puncture-lavage over metrosonography or CT scan in the diagnosis of homeoperitoneu. The diagnostic performance of CT, TDM in the identification of lesions solid organs is very much better that that of ultrasonography. The diagnosis of an isolated lesion of a hallow viscus benefited from progress in imaging to a much lesser degree an peritoneal puncture lavage with leucocyte count remains the key examination. The diagnostic strategy must be based on the patient's clinical condition and on this hierarchy of complementary investigations.

[Acute colonic pseudo-obstruction or Ogilvie syndrome]

Acute colonic pseudo-obstruction is a clinical condition with the symptoms, signs and radiological appearances of acute large bowel obstruction but without any apparent mechanical cause. The mortality rate for patients undergoing surgery was 57%. The incidence of caecal-perforation was 1 for 7 patients. The pathogenesis of the syndrome is unknown but in more then 80% of cases many conditions that have been associated with this syndrome. The efficacy of prepulsid agents for the treatment of syndrome remains to be assessed in a controlled study. In our patients clinical observation, radiologic studies and direct observation during several hours of surgery had shown a complete lack of propulsive motility within of the large bowel. This can be related to the ganglionitis and later to the aganglionosis of the mesenteric plexus.

[Observations regarding surgical treatment in liver trauma]

The high mortality rate in hepatic trauma is a concern for the surgeons on duty, who most know the physiopathological problems and the decisions needed in view of both hepatic and extrahepatic injures. The mortality rate from liver trauma has fallen from 60% at the beginning of this century, blunt trauma to the abdomen from accidents, is responsible for 80-90% of all liver injures in Europe. The severity of liver injuries in 268 patients in a prospective study (1978-1998), were treated according to a defined protocol. Non operative management was used in first day, for those who were haemodynamically stable on admission. In unstable patients who proceeded to surgery, under optimal condition the mortality rate was 34.3%. Death in patients with multiple injures should only rarely result from liver trauma. 92 patients with minor injures (grade I-II) were treated by simple suture, with mortality rate of 6%. 116 patients (43%) sustained complex hepatic injures (grade III to V); 64 patients with grade III (23%), 36 with grade IV (13%). 16 Patients (5%) grade V, injury under went finger fracture of hepatic parenchyma alone 36. The mortality rate in this group was 18% (III), 36% (IV). 16 patients with grad V injury were managed with 68% mortality rate. Juxtahepatic veins and retrohepatic V.C.I. injury continue to carry a prohibitive mortality rate (90-100%).

[Treatment of hernias and eventrations with alloplastic material (Mersilene type mesh)]

Between 1973 and 1979 the authors have performed 126 interventions, as follows: 27 hernias (18 of the inguinal type and 9 umbilical ones), and 99 eventration. They used alloplastic materials for consolidation or substitution of the musculo-aponevrotic wall of mediocre quality. In practice the "Mersilene" alloplastic material was used, made of dacron fibers, which provides a series of advantages: good tolerance, efficient sterilisation without undergoing degradation, possibility for use in reparation of large wall defects, high resistance. The net was applied for consolidation purposes in most of the cases (111 in all), and was placed either above the aponevrosis, or pre- or intra-peritoneally. In 15 patients it was used for substitution, when eventration resulted in a large muscular-aponevrotic defect. The results were very good, and a single recidive was noted, as well as two partial rejections, that did not however result in recidives.