Observational Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2023; 15(7): 1465-1473
Published online Jul 27, 2023. doi: 10.4240/wjgs.v15.i7.1465
New classification system for radical rectal cancer surgery based on membrane anatomy
Hui-Hong Jiang, Zhi-Zhan Ni, Yi Chang, A-Jian Li, Wen-Chao Wang, Liang Lv, Jian Peng, Zhi-Hui Pan, Hai-Long Liu, Mou-Bin Lin
Hui-Hong Jiang, Zhi-Zhan Ni, Yi Chang, A-Jian Li, Wen-Chao Wang, Liang Lv, Jian Peng, Zhi-Hui Pan, Hai-Long Liu, Mou-Bin Lin, Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, China
Hui-Hong Jiang, Yi Chang, Hai-Long Liu, Mou-Bin Lin, Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai 200090, China
Author contributions: Lin MB conceived the study; Jiang HH, Li AJ, Wang WC and Lin MB performed the study; Lv L, Peng J and Pan ZH helped collect the data; Chang Y and Liu HL analyzed and interpreted the data; Jiang HH and Ni ZZ drafted the manuscript and shared first co-authorship; and all authors have read and approved the final manuscript.
Supported by the National Natural Science Foundation of China, No. 81874201; Technology Plan Project, No. 20Y11908300; Shanghai Medical Key Specialty Construction Plan, No. ZK2019A19; Shanghai Municipal Commission of Health and Family Planning, No. 202040122; and Shanghai Pujiang Program, No. 21PJD066.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Yangpu Hospital, Tongji University (LL-2020-SCI-001).
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE statement, and the manuscript was prepared and revised according to the STROBE statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mou-Bin Lin, MD, Surgical Oncologist, Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, No. 450 Tengyue Road, Shanghai 200090, China. 1500142@tongji.edu.cn
Received: February 1, 2023
Peer-review started: February 1, 2023
First decision: April 3, 2023
Revised: April 24, 2023
Accepted: May 25, 2023
Article in press: May 25, 2023
Published online: July 27, 2023
Processing time: 170 Days and 10.1 Hours
ARTICLE HIGHLIGHTS
Research background

The concept of membrane anatomy has been widely used in clinical practice, especially in rectal surgery and gynecology, but there are many differences between them. The hysterectomy includes a variety of procedures, and the radicality of hysterectomy was classified according to Querleu-Morrow classification. However, total mesorectal excision (TME) is currently the only surgical option for rectal cancer, regardless of tumor size, localization or even tumor stage. Therefore, it is necessary to establish a variety of surgical procedures apart from Heald’s TME for tailoring rectal cancer surgery.

Research motivation

Previous work has shown that there is an onion-like multilayered fascial structure around the rectum, with multiple spaces formed. According to the principle of membrane anatomy, we can take different spaces as the surgical plane to achieve radical resection according to local invasion of the tumor.

Research objectives

This study aims to establish a new classification for radical rectal cancer surgery on the basis of clarifying the three-dimensional membrane anatomy of the pelvic cavity.

Research methods

Detailed pelvic dissections were performed on 26 cadavers, and surgical observations were conducted in 212 rectal patients undergoing laparoscopic TME with or without lateral lymph node dissection (LLND). A three-dimensional model of member anatomy of the pelvis was established, and the related anatomical nomenclatures were clearly clarified. Then, we proposed a membrane anatomical and staging-oriented classification for radical rectal cancer surgery.

Research results

Both cadaveric dissection and laparoscopic observation show that, the fascia propria of the rectum, urogenital fascia, vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces (medial, middle and lateral). Thus, a new classification system for radical rectal cancer surgery was proposed based only on the lateral extent of resection. We described three types of radical surgery for rectal cancer, which can be precisely defined on a three-dimensional anatomical template, including a few subtypes that consider nerve preservation. The surgical planes of the proposed radical surgeries (types A to C) were located in the medial, middle, and lateral spaces, respectively. Types A surgery is a urogenital fascia-preserving procedure, type B surgery corresponds to the classical TME, and type C surgery is equivalent to TME plus LLND.

Research conclusions

In this study, a new anatomical and staging-oriented classification system for rectal cancer surgery was established, and may serve as a valuable tool for unifying terminology and tailoring the radicality during surgery for rectal cancer.

Research perspectives

We proposed a new and promising classification for radical rectal cancer surgery. However, this classification is established on the basis of anatomical and surgical concept and lacks the support of clinical outcome data, and therefore further clinical investigations are warranted to confirm its role.