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Son SY, Seo YS, Yoon JH, Hur BY, Bae JS, Kim SH. Diagnostic Performance of Rectal CT for Staging Rectal Cancer: Comparison with Rectal MRI and Histopathology. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:1290-1308. [PMID: 38107688 PMCID: PMC10721426 DOI: 10.3348/jksr.2022.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 12/19/2023]
Abstract
Purpose To compare the diagnostic performance of rectal CT with that of high-resolution rectal MRI and histopathology in assessing rectal cancer. Materials and Methods Sixty-seven patients with rectal cancer who underwent rectal CT with rectal distension using sonographic gel and high-resolution MRI were enrolled in this study. The distance from the anal verge/anorectal junction, distance to the mesorectal fascia (MRF), extramural depth (EMD), extramesorectal lymph node (LN) involvement, extramural venous invasion (EMVI), and T/N stages in rectal CT/MRI were analyzed by two gastrointestinal radiologists. The CT findings of 20 patients who underwent radical surgery without concurrent chemoradiotherapy were compared using histopathology. Interclass correlations and kappa statistics were used. Results The distance from the anal verge/anorectal junction showed an excellent intraclass correlation between CT and MRI for both reviewers. For EMD, the distance to the MRF, presence of LNs, extramesorectal LN metastasis, EMVI, T stage, and intermodality kappa or weighted kappa values between CT and MRI showed excellent agreement. Among the 20 patients who underwent radical surgery, T staging, circumferential resection margin involvement, EMVI, and LN metastasis on rectal CT showed acceptable concordance rates with histopathology. Conclusion Dedicated rectal CT may be on par with rectal MRI in providing critical information to patients with rectal cancer.
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Fukudome I, Maeda H, Okamoto K, Yamaguchi S, Fujisawa K, Shiga M, Dabanaka K, Kobayashi M, Namikawa T, Hanazaki K. Early stoma closure after low anterior resection is not recommended due to postoperative complications and asymptomatic anastomotic leakage. Sci Rep 2023; 13:6472. [PMID: 37081037 PMCID: PMC10119273 DOI: 10.1038/s41598-023-33697-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/18/2023] [Indexed: 04/22/2023] Open
Abstract
The safety of early stoma closure after lower anterior resection (LAR) for rectal cancer remains controversial. In this study, patients scheduled to undergo LAR and stoma creation for rectal cancer were recruited. In absence of anastomotic leakage on radiological examination, closure of the diverting ileostomy was performed within 2 weeks. The primary endpoint was incidence of the colorectal anastomosis leakage after early stoma closure. Because of the slow accrual rate, the study was closed before recruitment reached the planned number of patients (n = 20). Among the 13 patients enrolled between April 2019 and March 2021, early stoma closure was performed in seven patients (53.8%). Non-clinical anastomotic leakage, leakage identified only on radiological examination, occurred in five cases, resulting in rescheduling of stoma closure. One patient did not undergo early stoma closure due to ileus. After stoma closure, colorectal anastomotic leakage manifested in one case; its incidence rate was 14.2%. Surgical site infection occurred in 42.8% of patients. This study revealed that asymptomatic anastomotic leakage occurred frequently. Considering the low rate of successful cases and the high rate of complications, early stoma closure within 2 weeks after LAR should not be performed routinely. Trial registration: (UMIN000036382 registered on 03/04/2019).
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Affiliation(s)
- Ian Fukudome
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
| | - Hiromichi Maeda
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan.
| | - Ken Okamoto
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
- Cancer Treatment Center, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, Japan
| | - Sachi Yamaguchi
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
| | - Kazune Fujisawa
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
| | - Mai Shiga
- Department of Surgery, Niyodo Hospital, Ino-cho, Agawa-Gun, Kochi, 1369, Japan
| | - Ken Dabanaka
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
| | - Michiya Kobayashi
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
- Cancer Treatment Center, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, Japan
| | - Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
| | - Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Kohasu, Oko-Cho, Nankoku-City, Kochi, 783-8505, Japan
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Zhou J, Chen J, Wang M, Chen F, Zhang K, Cong R, Fan X, Yang J, He B. A study on spinal level, length, and branch type of the inferior mesenteric artery and the position relationship between the inferior mesenteric artery, left colic artery, and inferior mesenteric vein. BMC Med Imaging 2022; 22:38. [PMID: 35260088 PMCID: PMC8903147 DOI: 10.1186/s12880-022-00764-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background This study was aimed to explore the clinical application of dual-energy computed tomography (DECT) monoenergetic plus (mono+) imaging to evaluate anatomical variations in the inferior mesenteric artery (IMA). Methods The clinical and imaging data of 212 patients who had undergone total abdominal DECT were retrospectively analyzed. The post-processing mono+ technique was used to obtain 40-keV single-level images in the arterial phase. Three-dimensional reconstruction was performed to evaluate the relationship between the IMA root position and the spinal level, IMA length, and IMA branch type, as well as the position of the left colic artery (LCA) and inferior mesenteric vein (IMV) at the IMA root level. Results The IMA root was located at the L3 level in 78.3% of cases and at the L2/L3 level in 3.3%. The highest vertebral level of IMA origin was L2 (4.2%), and the lowest was L4 (7.1%). The distance from the IMA root to the level of the sacral promontory was 99.58 ± 13.07 mm, which increased with the elevation of the IMA root at the spinal level. Of the patients, 53.8% demonstrated Type I IMA, 23.1% Type II, 20.7% Type III, and 2.4% Type IV. The length of the IMA varied from 13.6 to 66.0 mm. 77.3% of the IMAs belonged to Type A, the adjacent type, and 22.7% to Type B, the distant type. Conclusion DECT mono+ can preoperatively evaluate the anatomical characteristics of the IMA and the positional relationship between the LCA and IMV at the IMA root level, which would help clinicians plan individualized surgery for patients.
DECT mono+ optimal energy level can preoperatively determine the position of the IMA root. DECT mono+ can preoperatively evaluate the anatomical characteristics of the IMA. DECT mono+ can preoperatively determine the positional relationship between the LCA and IMV at the IMA root level.
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Affiliation(s)
- Jie Zhou
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China.,Department of Radiology, Changzhou Hospital of Traditional Chinese Medicine, Jiangsu, 213000, China
| | - Jinghao Chen
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Meirong Wang
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Feixiang Chen
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Kun Zhang
- Department of Electrical Engineering, Nantong University, Jiangsu, 226001, China
| | - Ruochen Cong
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Xiaole Fan
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Jushun Yang
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China.
| | - Bosheng He
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China. .,Clinical Medicine Research Center, Affiliated Hospital 2 of Nantong University, Jiangsu, 226001, China. .,Nantong Key Laboratory of Intelligent Medicine Innovation and Transformation, Jiangsu, 226001, China.
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Gatzinsky C, Redfors S, Borg H, Linnér C, Sillén U, Sjöström S. High-Resolution Anorectal Manometry-A Prospective Cohort Study in Healthy Infants. J Pediatr Gastroenterol Nutr 2022; 74:e57-e64. [PMID: 34732647 DOI: 10.1097/mpg.0000000000003350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Functional gastrointestinal disorders (FGD) are common during early childhood. In severe defecation disorders, anorectal manometry (AM) is done to exclude aganglionosis. High-resolution anorectal manometry (HRAM) can probably improve diagnostics but normative data in infants are scarce. This study aims to provide HRAM data in healthy infants overall and in subgroups of infants with FGD, defined as functional constipation (FC), infant colic (IC), and infant dyschezia (ID) (ROME 3 criteria). METHODS This prospective observational cohort study enrolled healthy term infants, having HRAM at 2 and 6 months, using a water-perfused pediatric anorectal silicone catheter. Data were provided for presence of anorectal waves and recto anal inhibitory reflex (RAIR), volume needed to elicit RAIR and anal resting pressure (ARP). Questionnaires at 2 and 6 months identified subjects with FC, IC, and ID. RESULTS A total of 187 HRAM investigations were done in 107 infants, without any complications. Normal RAIR was found in all, at least on one occasion. Mean ARP increased between 2- and 6-month investigations in infants without FGD. No other differences in HRAM data could be seen between infants with or without an FGD. At 2 months FC, IC, and ID were seen (2%, 4%, and 17%), whereas at 6 months only FC and ID were seen (7% and 1%). CONCLUSION We can provide data on HRAM in infants at 2 and 6 months of age. When performing repeated HRAM in healthy infants, RAIR was found in all subjects. HRAM is safe, easy tolerable, and can be recommended in infants with or without FGD.
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Affiliation(s)
| | - Staffan Redfors
- Department of Pediatric Clinical Physiology, Queen Silvia Children's Hospital, Göteborg, Sweden
| | | | - Christina Linnér
- Department of Pediatric Clinical Physiology, Queen Silvia Children's Hospital, Göteborg, Sweden
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Tsarkov PV, Efetov SK, Zubayraeva AA, Puzakov KB, Oganyan NV. Surgeon's role in CT-based preoperative determination of inferior mesenteric artery anatomy in colorectal cancer treatment. Khirurgiia (Mosk) 2022:40-49. [PMID: 36073582 DOI: 10.17116/hirurgia202209140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The inferior mesenteric artery (IMA) is a blood vessel of great importance in left colon and rectal cancer surgery. We aimed to determine the role of surgeons in computed tomography (CT) based vascular anatomy interpretation. METHOD Patients with left colon and rectal cancer treated surgically with D3 lymph node dissection and selective vascular ligation were included in this study. All patients (n=250) underwent preoperative CT with intravenous contrast. The IMA anatomy was schematically depicted by surgeon based on CT interpretation. Intraoperatively anatomy was defined by skeletonisation of the IMA. All patients had segmental resection with selective vascular ligation. The concurrence of prospectively obtained results were evaluated by intraclass correlation and Kendall's tau-b test. Misinterpretation of IMA anatomy was analysed by CT-specialist. RESULTS The preoperative and intraoperative IMA anatomy features were correctly interpreted in 237 cases (in 94.8%) within skeletonisation extent, which is supported by high level of agreement and concordance of preoperative data regards to intraoperative findings (K=0.926; p<0.001; CC=0.912; p<0.001). As a result of the CT-based evaluation of the IMA, E, K, and H types of branching patterns were proposed. IMV position was mistakenly identified in 2.6% of cases. CONCLUSION Surgeons are able to evaluate the IMA anatomy accurately with CT and use it in routine preoperative planning. The E, K, and H branching types may be used when defining approach to skeletonisation and level of vascular ligation.
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Affiliation(s)
- P V Tsarkov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - S K Efetov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Zubayraeva
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - K B Puzakov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - N V Oganyan
- Sechenov First Moscow State Medical University, Moscow, Russia
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Fukudome I, Maeda H, Okamoto K, Kuroiwa H, Yamaguchi S, Fujisawa K, Shiga M, Dabanaka K, Kobayashi M, Namikawa T, Hanazaki K. The safety of early versus late ileostomy reversal after low anterior rectal resection: a retrospective study in 47 patients. Patient Saf Surg 2021; 15:7. [PMID: 33423686 PMCID: PMC7798274 DOI: 10.1186/s13037-020-00275-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/07/2020] [Indexed: 02/08/2023] Open
Abstract
Background This study aimed to clarify the safety of early closure in diverting ileostomy with lower anterior rectal-cancer resection. Methods We retrospectively reviewed consecutive 47 patients who underwent diverting ileostomy with lower rectal-cancer resection between May 2009 and October 2017. The results of the stoma closure were compared between patients who underwent stoma closure within 90 days (early closure [EC] group) and those who underwent late closure (LC group; closure after 90 days). Because of the small sample size, the frequency of severe complications post closure was analyzed. Results Among 47 patients, 29 were in the EC group. Postoperative complications occurred in 48.3% (14/29) and 27.8% (5/18) of patients in the EC and LC groups, respectively. This difference was due to minor complications (Clavien-Dindo Classification I/II), such as superficial incisional surgical site infections (n=5) in the EC group. The rate of severe complications (Clavien-Dindo Classification ≥ III) was similar between the groups (20.7% vs. 16.7%, p=1, Fisher’s exact test). Conclusions No association was observed between the time of closure and development of major complications; however, there was an increased likelihood of minor complications after EC. This study provides a basis on which future treatment guidelines for early stoma closure may be developed without affecting patient quality of life.
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Affiliation(s)
- Ian Fukudome
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan.
| | - Hiromichi Maeda
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
| | - Ken Okamoto
- Cancer Treatment Center, Kochi Medical School, Kohasu, Oko-cho, Nankoku-city, 783-8505, Kochi, Japan
| | - Hajime Kuroiwa
- Integrated Center for Advanced Medical Technologies (ICAM-Tech), Kochi Medical School, Nankoku-city, Japan
| | - Sachi Yamaguchi
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
| | - Kazune Fujisawa
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
| | - Mai Shiga
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
| | - Ken Dabanaka
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
| | - Michiya Kobayashi
- Cancer Treatment Center, Kochi Medical School, Kohasu, Oko-cho, Nankoku-city, 783-8505, Kochi, Japan
| | - Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
| | - Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, 783-8505, Nankoku-city, Kochi, Japan
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Shaibu Z, Chen ZH, Theophilus A, Mzee SAS. Preservation of the Arterial Arc Formed by Left Colic Artery, Proximal Inferior Mesenteric Artery, and the First Branch of Sigmoid Arteries in Anus Saving Treatment of Low Rectal Cancer. Am Surg 2020; 87:1956-1964. [PMID: 33382355 DOI: 10.1177/0003134820983188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low anterior, ultralow anterior, and intersphincteric resection are conventional, elective anus-sparing techniques for low rectal cancer, and good prognosis depends on a good blood supply and tension-free anastomosis. AIM The goal is to assess the effect of preserving the arc formed by the left colic and proximal inferior mesenteric arteries (IMAs), and first branch of the sigmoid arteries on the anastomotic blood supply, tension, and leakage rate in anus-sparing surgery for low rectal cancer. METHOD From 2011 to 2020, a patient with low rectal cancer resection was distributed into the ligation group (42 cases with inferior mesenteric artery ligation) and the preservation group (61 cases with preservation of the left colic and proximal IMAs and first branch of the sigmoid artery). RESULTS We evaluated patient characteristics, operative results, morbidity, and postoperative follow-up results. There were comparable outcomes between ligation and preservation groups in relations to the number of patients in each operative procedure, duration of surgery, operative blood loss, postoperative hospital stay, and the number of patients with protective stoma (P >.05). In postoperative morbidity, there were similar outcomes between ligation and preservation groups in terms of anastomotic subclinical dehiscence, bleeding and stricture, and urinary retention (P >.05). There were significant differences in anastomotic leakage and intra-abdominal abscess (P < .05). CONCLUSION Preservation of the arterial arc formed by left colic artery, proximal IMA, and the first branch of sigmoid arteries with apical lymph node dissection could increase anastomotic blood supply, reduce anastomotic tension, and leakage rate in anus-saving treatment of low rectal cancer.
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Affiliation(s)
- Zakari Shaibu
- Department of Gastrointestinal Surgery, 12676Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China.,School of Medicine, 12676Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhi-Hong Chen
- Department of Gastrointestinal Surgery, 12676Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Acquah Theophilus
- Department of Gastrointestinal Surgery, 12676Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, China.,School of Medicine, 12676Jiangsu University, Zhenjiang, Jiangsu, China
| | - Said A S Mzee
- School of Medicine, 12676Jiangsu University, Zhenjiang, Jiangsu, China.,Department of Gastrointestinal Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
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8
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Ammendola M, Ruggiero M, Talarico C, Memeo R, Ammerata G, Capomolla A, Filippo R, Romano R, Pallio S, Navarra G, Montemurro S, Currò G. No Coil® placement in patients undergoing left hemicolectomy and low anterior resection for colorectal cancer. World J Surg Oncol 2020; 18:327. [PMID: 33302970 PMCID: PMC7731543 DOI: 10.1186/s12957-020-02096-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the most common tumor of the gastrointestinal tract. Anastomotic leak (AL) and prolonged postoperative ileus (PPOI) are two important complications of colorectal surgery. In this observational retrospective study, we evaluated the positive effects of transanal tube No Coil® in patients with CRC undergoing low anterior resection (LAR) and left hemicolectomy (LC). METHODS Thirty-eight cases and forty controls resulted eligible for the final sample. No Coil® placement (SapiMed Spa, Alessandria, Italy) was considered an inclusion criteria for the case group. No Coil® was placed immediately after the end of surgical treatment. RESULTS PPOI was significantly more frequent in the control group. AL was evident in 1 patient (2.6%) of cases and 3 patients (7.5%) of controls. No statistical difference was found in AL occurrence between groups. POI days and AL resulted associated with hospital stay. POI days were negatively associated with No Coil placement and positively with AL. CONCLUSION With our preliminary data, we suggest that No Coil® placement can be considered as a valuable procedure assisting colorectal surgery, but further studies are required to confirm and enlarge actual evidence.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy.
| | - Michele Ruggiero
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Carlo Talarico
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, "F. Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Giorgio Ammerata
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Antonella Capomolla
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Rosalinda Filippo
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Socrate Pallio
- Department of Clinical and Experimental Medicine, Digestive Diseases Endoscopy Unit, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy.,Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
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9
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Fung TLD, Tsukada Y, Ito M. Essential anatomy for total mesorectal excision and lateral lymph node dissection, in both trans-abdominal and trans-anal perspective. Surgeon 2020; 19:e462-e474. [PMID: 33248924 DOI: 10.1016/j.surge.2020.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Total Mesorectal Excisions (TME) is the standard treatment of rectal cancer. It can be performed under laparoscopic, robotic or transanal approach. Inadvertent injury to surrounding structure like autonomic nerves is avoidable, no matter which approach is adopted. Lateral lymph node dissection (LLND) is a less commonly performed pelvic operation involving dissection in an unfamiliar area to most general surgeons. This article aims to clarify all the essential anatomy related to these procedures. METHODS We performed thorough literature search and revision on the pelvic anatomy. Our cases of TME and LLND, under either laparoscopic or transanal approach, were reviewed. We integrated the knowledge from literatures and our own experience. The result was presented in details, together with original figures and intra-operative photos. MAIN FINDINGS Anatomy of pelvic fascia, autonomic nerve system, anal canal and sphincter complex are core knowledge in performing TME and LLND. CONCLUSIONS Thorough understanding of the pelvic anatomy enables colorectal surgeons to master these procedures, avoid complication and perform extended resection. On the other hand, surgeons can appreciate the complex pelvic anatomy easier by seeing the pelvis in opposite angles (transabdominal and transaanal view).
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Affiliation(s)
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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10
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Hope TA, Gollub MJ, Arya S, Bates DDB, Ganeshan D, Harisinghani M, Jhaveri KS, Kassam Z, Kim DH, Korngold E, Lalwani N, Moreno CC, Nougaret S, Paroder V, Paspulati RM, Golia Pernicka JS, Petkovska I, Pickhardt PJ, Rauch GM, Rosenthal MH, Sheedy SP, Horvat N. Rectal cancer lexicon: consensus statement from the society of abdominal radiology rectal & anal cancer disease-focused panel. Abdom Radiol (NY) 2019; 44:3508-3517. [PMID: 31388697 DOI: 10.1007/s00261-019-02170-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Standardized terminology is critical to providing consistent reports to referring clinicians. This lexicon aims to provide a reference for terminology frequently used in rectal cancer and reflects the consensus of the Society of Abdominal Radiology Disease Focused Panel in Rectal cancer. This lexicon divided the terms into the following categories: primary tumor staging, nodal staging, treatment response, anal canal anatomy, general anatomy, and treatments.
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Affiliation(s)
- Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA, 94143, USA.
- Department of Radiology, San Francisco VA Medical Center, San Francisco, CA, USA.
- UCSF Helen, Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - David D B Bates
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Kartik S Jhaveri
- University of Toronto University Health Network, Toronto, ON, Canada
| | - Zahra Kassam
- Schulich School of Medicine, Western University, London, ON, Canada
| | - David H Kim
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Neeraj Lalwani
- Department of Radiology, Section of Abdominal Imaging, Wake Forest University and Baptist Medical Center, Winston-Salem, NC, USA
| | | | - Stephanie Nougaret
- Montpellier Cancer Research Institute, Montpellier, France
- Department of Radiology, Montpellier Cancer Institute, INSERM, U1194, University of Montpellier, Montpellier, France
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raj M Paspulati
- Department of Radiology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | | | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Perry J Pickhardt
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Gaiane M Rauch
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael H Rosenthal
- Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Natally Horvat
- Department of Radiology, Hospital Sirio-Libanes, São Paulo, São Paulo, Brazil
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Νikolouzakis ΤΚ, Mariolis-Sapsakos T, Triantopoulou C, De Bree E, Xynos E, Chrysos E, Tsiaoussis J. Detailed and applied anatomy for improved rectal cancer treatment. Ann Gastroenterol 2019; 32:431-440. [PMID: 31474788 PMCID: PMC6686088 DOI: 10.20524/aog.2019.0407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.
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Affiliation(s)
- Τaxiarchis Κonstantinos Νikolouzakis
- Laboratory of Anatomy-Histology-Embryology, Medical School of Heraklion, University of Crete (Taxiarchis Konstantinos Nikolouzakis, John Tsiaoussis)
| | - Theodoros Mariolis-Sapsakos
- Surgical Department, National and Kapodistrian University of Athens, Agioi Anargyroi General and Oncologic Hospital of Kifisia, Athens (Theodoros Mariolis-Sapsakos)
| | | | - Eelco De Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Crete (Eelco De Bree)
| | - Evaghelos Xynos
- Colorectal Surgery, Creta Interclinic, Heraklion, Crete (Evaghelos Xynos)
| | - Emmanuel Chrysos
- Department of General Surgery, University Hospital of Heraklion, Crete (Emmanuel Chrysos), Greece
| | - John Tsiaoussis
- Laboratory of Anatomy-Histology-Embryology, Medical School of Heraklion, University of Crete (Taxiarchis Konstantinos Nikolouzakis, John Tsiaoussis)
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Emmanuel A, Chohda E, Lapa C, Miles A, Haji A, Ellul J. Defunctioning Stomas Result in Significantly More Short-Term Complications Following Low Anterior Resection for Rectal Cancer. World J Surg 2018; 42:3755-3764. [PMID: 29777268 PMCID: PMC6182750 DOI: 10.1007/s00268-018-4672-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma. METHODS A retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications. RESULTS Two hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma. CONCLUSION Patients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas. STUDY REGISTRATION Registered at www.researchregistry.com (UIN: researchregistry3412).
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Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ezzat Chohda
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Christo Lapa
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Andrew Miles
- Department of Colorectal Surgery, Hampshire Hospitals NHS Foundation Trust, Wessex, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Joe Ellul
- Department of Colorectal Surgery, King’s College Hospital NHS Foundation Trust, London, UK
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Zeng J, Su G. High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis. World J Surg Oncol 2018; 16:157. [PMID: 30071856 PMCID: PMC6091013 DOI: 10.1186/s12957-018-1458-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 07/26/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The ideal level of ligation of the inferior mesenteric artery (IMA) during curative resection of sigmoid colon and rectal cancer is still controversial. The aim of this meta-analysis was to examine the impact of high ligation and low ligation of the IMA on anastomotic leakage, overall morbidity, postoperative mortality, and oncological outcomes in patients undergoing surgery for sigmoid colon and rectal cancer. METHODS PubMed, EMBASE, Web of Science, and BioMed Central databases were searched to identify relevant articles published from May 1953 to March 2018. A total of 18 articles (14 non-randomized studies and 4 randomized clinical trials) were identified. Review Manager 5.3 software was used for analysis of data. The pooled odds ratio (OR) and weighted mean difference (WMD), with 95% CI, were calculated using either the fixed effects model or random effects model. RESULTS Of the 5917 patients included in this meta-analysis, 3652 patients underwent low ligation of the IMA and 2265 patients underwent high ligation of the IMA. Anastomotic leakage rate was 9.8% in high ligation patients vs. 7.0% in low ligation patients; the risk of anastomotic leakage was significantly higher in high ligation patients (OR = 1.33; 95% CI 1.10-1.62; P = 0.004). What is more, overall morbidity was also significantly higher in high ligation patients (OR = 1.39; 95% CI, 1.05-1.68; P = 0.05). Postoperative mortality, number of harvested lymph nodes, overall recurrence rate, and 5-year survival rate did not differ significantly between the two groups. CONCLUSION Low ligation of the IMA during curative resection of sigmoid colon and rectal cancer appears to be associated with lower risk of anastomotic leakage and overall morbidity. However, there was no significant advantage of low ligation over high ligation of IMA in terms of postoperative mortality, the number of harvested lymph nodes, overall recurrence rate, or 5-year survival rate.
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Affiliation(s)
- Jinshui Zeng
- Department III of Gastrointestinal Surgery, First Affiliated Hospital of Xiamen University , Xiamen, 361003, Fujian, China
| | - Guoqiang Su
- Department III of Gastrointestinal Surgery, First Affiliated Hospital of Xiamen University , Xiamen, 361003, Fujian, China.
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Wickramasinghe DP, Jayarajah U, Samarasekera DN. Duration taken for the anal sphincter pressures to stabilize prior to anorectal manometry. BMC Res Notes 2018; 11:354. [PMID: 29871700 PMCID: PMC5989387 DOI: 10.1186/s13104-018-3451-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Anorectal manometry (ARM) is an integral part of evaluating the anal sphincter function. The current recommendation of waiting for 5 min (lead-in-time) prior to beginning the recording has no evidence. A prolonged procedure may reduce patient compliance. RESULTS We analyzed data from 100 consecutive patients who underwent 3-dimensional ARM at a single center. Their pressure studies were analyzed in consecutive 10-s segments, beginning from the time of insertion of the probe into the anal canal. We defined stabilization of the pressure as the absence of a pressure difference among two consecutive 10-s segments. The study population had 31 males. Their mean age was 33.0 years (SD-14.4). The mean time for the pressure to stabilize was 84.2 s (SD-29.5), range 17.2-203.7 s, 95th percentile 136.2 s. Eleven and one participant(s) took longer than 120 and 150 s for the pressure to stabilize, respectively. There was no correlation of sex (Mann-Whitney U test, p = 0.89) and the time to pressure stabilization. Age and the time to stabilize (Spearman rho - 0.246, p = 0.017) showed a weak negative correlation. A lead-in-time of 5 min, as recommended by present guidelines may be unnecessary. Waiting for 150 s/2½ min may be sufficient and will minimize the procedure duration.
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Affiliation(s)
| | - Umesh Jayarajah
- Department of Surgery, Faculty of Medicine, University of Colombo, P.O. Box 271, Kynsey Road, Colombo 8, Sri Lanka
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Rao X, Zhang J, Liu T, Wu Y, Jiang Y, Wang P, Chen G, Pan Y, Wu T, Liu Y, Wan Y, Huang S, Wang X. Prognostic value of inferior mesenteric artery lymph node metastasis in cancer of the descending colon, sigmoid colon and rectum. Colorectal Dis 2018; 20:O135-O142. [PMID: 29577541 DOI: 10.1111/codi.14105] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/01/2018] [Indexed: 12/13/2022]
Abstract
AIM This study aimed to analyse the potential significance of metastasis to the inferior mesenteric artery lymph node (IMA-LN) in patients with malignancy of the left colon and rectum. METHOD A retrospective analysis of a cohort of 890 patients collected prospectively who underwent radical resection of a primary tumour of the descending colon, sigmoid colon and rectum in our department from 1 January 2009 to 31 December 2015 was performed. Patients were divided into an IMA-LN metastasis (IMA-LN (+)) group (n = 51) and a non IMA-LN metastasis (IMA-LN (-)) group (n = 839). A total of 801 patients were followed by a designated member of the study staff. Clinical features, pathological characteristics, recurrence patterns and survival rates were compared between the two groups. RESULTS In the IMA-LN (+) group, the risk ratio of overall recurrence and tumour related death was 7.786 (95% CI 4.142-14.637) and 7.756 (95% CI 4.142-14.525) respectively. Significant differences were found in overall survival (log-rank: χ2 = 69.06, P < 0.0001) and disease-free survival (log-rank: χ2 = 69.06, P < 0.0001) between the two groups. Furthermore, there were significant differences in overall survival (log-rank: χ2 = 18.47, P < 0.0001) and disease-free survival (log-rank: χ2 = 16.99, P < 0.0001) between the IMA-LN (-) and IMA-LN (+) subgroups of patients with Stage N2 disease. Multivariate survival analysis indicated that IMA-LN (+) was an independent risk factor of poor prognosis. There was no difference in the prognosis between high tie and low tie with IMA-LN dissection. CONCLUSION Inferior mesenteric artery lymph node metastasis was an independent predictive factor for high systemic recurrence. Low ligation of the IMA with IMA-LN dissection was not inferior to high ligation.
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Affiliation(s)
- X Rao
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - J Zhang
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - T Liu
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - Y Wu
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - Y Jiang
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - P Wang
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - G Chen
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - Y Pan
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - T Wu
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - Y Liu
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - Y Wan
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - S Huang
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
| | - X Wang
- Department of General Surgery, Peking University First Hospital, Beijing, PR China
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Fan YC, Ning FL, Zhang CD, Dai DQ. Preservation versus non-preservation of left colic artery in sigmoid and rectal cancer surgery: A meta-analysis. Int J Surg 2018; 52:269-277. [PMID: 29501795 DOI: 10.1016/j.ijsu.2018.02.054] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/29/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to conduct a meta-analysis comparing the oncological, intraoperative and safety outcomes in sigmoid and rectal cancer surgery with and without preservation of the left colic artery (LCA). METHOD We searched Medline, Embase, China National Knowledge Infrastructure (CNKI), and PubMed databases for relevant articles published between 1962 and 2017. Randomized and non-randomized clinical trials were identified and included in the study. End-points evaluated included 5-year mortality, number of patients with retrieved positive metastatic lymph nodes (LN) at the root of inferior mesenteric artery (IMA), number of retrieved LNs, morbidity, mortality, recurrence, bowel obstruction, intraoperative blood loss, anastomotic leakage, operation time, surgical site infection and postoperative bleed. Meta-analysis was conducted using RevMan 5.3 software. The odds ratio (OR) with 95% confidence intervals (CI) was used to analyze dichotomous data. RESULTS Seventeen studies including 6247 patients were identified for the meta-analysis. Meta-analysis revealed that preserving the LCA was associated with reduced anastomotic leakage rate (OR, 0.78; 95% CI, 0.62-0.98; P = 0.03). There were no significant differences between the two groups with respect to the 5-year mortality, number of retrieved LNs, number of patients with retrieved positive metastatic LNs at the root of IMA, morbidity, mortality, recurrence, bowel obstruction, intraoperative blood loss, operation time, surgical site infection and postoperative bleed. CONCLUSION In comparison with ligating the left colic artery, preserving the left colic artery seems to achieve comparable success with acceptable safety outcomes and we suggest to preserve the LCA in the sigmoid and rectal cancer surgeries. However, more multicenter randomized controlled trials are required to further evaluate the efficacy and safety of preserving the left colic artery in surgeries.
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Affiliation(s)
- Yu-Chen Fan
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Fei-Long Ning
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China; Department of General Surgery, Xuzhou Hospital of Traditional Chinese Medicine, Xuzhou, Jiangsu, China
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Dong-Qiu Dai
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China; Cancer Center, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
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Abstract
BACKGROUND The benefits of adjuvant chemotherapy in the treatment of colorectal cancer are well established. Chemotherapy-induced diarrhea is a common adverse effect of these regimens. The occurrence of chemotherapy-induced diarrhea not only directly affects patient health but may also compromise treatment efficacy because of consequent dosing alterations or discontinuation. OBJECTIVE This study aimed to investigate the effect of diverting loop ileostomy during chemotherapy on the occurrence and consequences of chemotherapy-induced diarrhea. DESIGN This was a retrospective evaluation of a prospective surgical database. SETTINGS This was a single-institution retrospective study. PATIENTS All patients receiving curative adjuvant chemotherapy after anterior resection for colorectal cancer at Auckland Hospital from 2002 to 2013 were retrospectively evaluated. MAIN OUTCOME MEASURES Patient-, perioperative-, and chemotherapy-related variables were collected. Chemotherapy-induced diarrhea occurrence was graded according to National Cancer Institute Common Terminology Criteria for Adverse Events. Logistic regression analysis was performed to identify independent predictors for chemotherapy-induced diarrhea occurrence, treatment modifications, and hospital admission. RESULTS A total of 109 identified patients received 691 chemotherapy cycles; 84% of patients with a diverting ileostomy experienced chemotherapy-induced diarrhea compared with 47% in those who were not defunctioned (p < 0.01). On logistic regression analysis, the presence of a diverting ileostomy during chemotherapy was an independent predictor of chemotherapy-induced diarrhea grade 3 or higher (OR, 13.6 (95% CI: 1.2-150.9); p = 0.02), the need for a dosing reduction (OR, 4.0 (95% CI: 1.3-12.4); p = 0.02), and the need for any modification in the chemotherapy regimen (OR, 3.4 (95% CI: 1.2-9.6); p = 0.02). LIMITATIONS This study is limited by its retrospective design, potentially limiting the accuracy of chemotherapy-induced diarrhea grade reporting. CONCLUSIONS The presence of an ileostomy during adjuvant chemotherapy is a predictor of severe chemotherapy-induced diarrhea and the need for modifications in the chemotherapy regimen. This may have important consequences for long-term survival. Prospective investigation is needed to further assess the impact of diverting ileostomy on the delivery of chemotherapy and oncologic outcomes.
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Wickramasinghe DP, Perera CS, Senanayake H, Samarasekera DN. Three-Dimensional Anorectal Manometry Findings in Primigravida. Dig Dis Sci 2015. [PMID: 26204973 DOI: 10.1007/s10620-015-3784-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vaginal delivery is an identified risk factor for anal sphincter injury. Therefore, to identify postpartum injury, an antepartum value or a normal range is required. However, at present, the normal values of 3D manometry are not available for primigravida or pregnant mothers. AIMS Our study aims at describing normal values of 3D manometry in primigravida. METHODS We analyzed 3DARM data of 101 consecutive primigravid mothers in the third trimester. 3DARM was performed using the Given Imaging(®) ManoScan system. RESULTS The mean age was 24.7 (SD 5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD 18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD 52.96) mmHg. The mean length of the high-pressure zone (HPZ) was 3.67 (SD 0.52) cm. Mean volumes for initial rectal sensation, urge, and discomfort were 50.36 (± 25.57), 76.70 (± 35.17), and 143.40 (± 66.26) ml, respectively. The pressure asymmetry was highest in the lower anal sphincter and lowest in the mid-sphincter. There was a statistically significant relationship between the HPZ and RP (Pearson ρ -0.23, p = 0.01), height (Pearson ρ 0.22, p = 0.028), and weight (Pearson ρ 0.25, p = 0.012). There were no statistically significant correlations between age, height, or weight with RP, SP, or balloon fill volumes. The characteristic appearance of the normal RP and SP was clearly visualized in all patients. CONCLUSIONS Normal 3DARM values for Sri Lankan primigravid mothers have been established. These may be used as reference values by other investigators.
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Affiliation(s)
- D P Wickramasinghe
- Department of Surgery, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka.
| | - C S Perera
- Department of Surgery, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka.
| | - H Senanayake
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - D N Samarasekera
- Department of Surgery, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka.
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Maeda H, Okamoto K, Namikawa T, Akimori T, Kamioka N, Shiga M, Dabanaka K, Hanazaki K, Kobayashi M. Rarity of late anastomotic leakage after low anterior resection of the rectum. Int J Colorectal Dis 2015; 30:831-4. [PMID: 25862318 DOI: 10.1007/s00384-015-2207-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Late anastomotic leakage is reported to account for half of all anastomotic leakages after low anterior resection of the rectum. An important clinical question is whether late and early anastomotic leakages are different entities. METHODS We retrospectively reviewed the medical records of patients who experienced anastomotic leakage after low anterior resection in two Japanese hospitals. The clinical characteristics were extracted and analyzed. RESULTS During the study period, 179 patients underwent low anterior resection. A pelvic drainage tube was routinely utilized in all cases and was generally removed 4 to 6 days after the operation. Twenty-six patients had anastomotic leakage; the diagnosis was based on fecal contamination of the drainage in 24 cases. The median interval between operation and detection of anastomotic leakage was 3.5 days. Anastomotic leakage was diagnosed within 7 days of the operation in 25 cases and on postoperative day 20 (after hospital discharge) in one case. There was no instance of anastomotic leakage diagnosed more than 30 days after the operation. There was no relationship between clinical variables and days of leakage diagnosis. CONCLUSION The rarity of late anastomotic leakage in our study, compared with previous studies, may relate to the relatively extended period of pelvic drainage tube usage in our institutes, which likely shortens the interval before leakage diagnosis. Our results suggest that late anastomotic leakage is a delayed symptom of subtle early anastomotic leakage rather than a separate entity.
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Affiliation(s)
- Hiromichi Maeda
- Cancer Treatment Center, Kochi Medical School Hospital, Kohasu, Oko-cho, Nankoku-city, Kochi, 783-8505, Japan,
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Kulaylat MN. Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance. World J Surg Proced 2015; 5:27-40. [DOI: 10.5412/wjsp.v5.i1.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023] Open
Abstract
Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.
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Wells CI, Vather R, Chu MJJ, Robertson JP, Bissett IP. Anterior resection syndrome--a risk factor analysis. J Gastrointest Surg 2015; 19:350-9. [PMID: 25326125 DOI: 10.1007/s11605-014-2679-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/08/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Evacuatory dysfunction after distal colorectal resection varies from incontinence to obstructed defaecation and is termed anterior resection syndrome. The aim of this study was to identify risk factors for the development of anterior resection syndrome. METHODS All anterior resections undertaken at Auckland Hospital from 2002 to 2012 were retrospectively evaluated. An assortment of patient and peri-operative variables were recorded. Cases were stratified by the occurrence of anterior resection syndrome symptoms from 1 to 5 years post-operatively. RESULTS A total of 277 patients were identified. Prevalence of anterior resection syndrome decreased progressively from 61 % at 1 year to 43 % at 5 years. Univariate analysis identified anastomotic height, surgeon, pT stage, procedure year and temporary diversion ileostomy as recurring significant correlates (p < 0.05). Logistic regression identified lower anastomotic height (odds ratio (OR) 2.11, 95 % confidence interval (CI) 1.05-4.27; p = 0.04) and obstructive presenting symptoms (OR 6.71, 95 % CI 1.00-44.80; p = 0.05) as independent predictors at 1 and 2 years, respectively. Post-operative chemotherapy was a predictor at 1 year (OR 1.93, 95 % CI 1.04-3.57; p = 0.03). Temporary diverting ileostomy was an independent predictor at 2 (OR 2.49, 95 % CI 1.04-5.95; p = 0.04), 3 (OR 4.17, 95 % CI 1.04-16.78; p = 0.04), 4 (OR 8.05, 95 % CI 1.21-53.6; p = 0.03), and 5 years (OR 49.60, 95 % CI 2.17-1134.71; p = 0.02) after adjusting for anastomotic height. CONCLUSIONS Anastomotic height, post-operative chemotherapy and obstructive presenting symptoms were independent predictors at 1 and 2 years. Temporary diversion ileostomy was an independent predictor for the occurrence of anterior resection syndrome at 2, 3, 4 and 5 years even after correcting for anastomotic height. Prospective assessment is required to facilitate more accurate risk factor analysis.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
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Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chang K, Johnson J, Waldron D, Condon E, El-Bassiouni M, Coffey J. A comparison of the usage of anal verge and dentate line in measuring distances within the rectum. INTERNATIONAL JOURNAL OF SURGERY OPEN 2015. [DOI: 10.1016/j.ijso.2016.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Guingané AN, Sombié RA, Bougouma A. [Anorectal malignant tumors in the hospital environment in Ouagadougou: epidemiological and diagnostic aspects]. Pan Afr Med J 2014; 18:26. [PMID: 25368715 PMCID: PMC4214564 DOI: 10.11604/pamj.2014.18.26.3003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 05/01/2014] [Indexed: 11/11/2022] Open
Abstract
Le but de notre étude était de décrire les caractéristiques épidémiologiques et diagnostiques des tumeurs malignes anorectales en milieu hospitalier à Ouagadougou. Il s'est agi d'une étude rétrospective et transversale qui a concerné les patients vus en endoscopie digestive basse au cours de la période allant du 29/09/1999 au 04/10/2008. À l'aide d'une fiche de collecte, nous avons recueilli, dans 4 structures sanitaires et 3 laboratoires d'anatomie et de cytologie pathologiques de la ville de Ouagadougou, les données à partir des comptes-rendus d'endoscopie digestive basse et des registres d'anatomie et de cytologie pathologiques. Durant la période de notre étude, 645 patients ont été examinés en anorectoscopie et 882 cas d'affections anorectales colligés. Les tumeurs malignes anorectales avec 61 cas (6,9%) occupaient la quatrième place après la maladie hémorroïdaire (45,6%), les anites (21,1%) et les fissures (13,9%). Elles regroupaient les cancers du rectum (4,2%) et les cancers de l'anus (2,7%). Vingt cancers anorectaux ont été histologiquement confirmés parmi lesquels l'adénocarcinome était le type histologique le plus retrouvé avec 17 cas. Les tumeurs malignes, quatrième affection anorectale la plus fréquente au cours de notre étude, constituent une préoccupation du fait de leur fréquence croissante, leur diagnostic souvent tardif et les difficultés liées à leur prise en charge surtout dans nos pays avec une population à faible revenu. La sensibilisation de la population et la prescription plus large de l'endoscopie digestive basse devraient permettre une meilleure prise en charge des patients.
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Affiliation(s)
| | - Roger Arsène Sombié
- Centre Hospitalier Universitaire Yalgado Ouédraogo (CHUY-O), Ouagadougou, Burkina Faso ; Unité de Formation et de Recherche en Sciences de la Santé (UFR-SDS), Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Alain Bougouma
- Centre Hospitalier Universitaire Yalgado Ouédraogo (CHUY-O), Ouagadougou, Burkina Faso ; Unité de Formation et de Recherche en Sciences de la Santé (UFR-SDS), Université de Ouagadougou, Ouagadougou, Burkina Faso
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Smart NJ, Pathak S, Boorman P, Daniels IR. Synthetic or biological mesh use in laparoscopic ventral mesh rectopexy--a systematic review. Colorectal Dis 2013; 15:650-4. [PMID: 23517144 DOI: 10.1111/codi.12219] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 12/04/2012] [Indexed: 12/11/2022]
Abstract
AIM Laparoscopic ventral mesh rectopexy (VMR) is a surgical option for internal and external rectal prolapse with low perioperative morbidity and low recurrence rates. Use of synthetic mesh in the pelvis may be associated with complications such as fistulation, erosion and dyspareunia. Biological meshes may avoid these complications, but the long-term outcome is uncertain. Debate continues as to which type of mesh is optimal for laparoscopic VMR. METHOD A literature search was performed of electronic databases including MEDLINE, Embase and Scopus (2000-12). Studies describing outcomes relating to the mesh were included for review. Only English language studies were included. RESULTS Thirteen observational studies reported the outcome of 866 patients following laparoscopic VMR. Eleven reported the outcome using synthetic mesh with a median follow-up ranging from 7 to 74 months. Two studies reported the outcome with biological mesh with a median follow-up of 12 months. Pooled analysis of the studies demonstrated that 767 patients had a repair with synthetic mesh and 99 with a biological implant. There was no difference in recurrence (3.7 vs 4.0%, P = 0.78) or mesh complications (0.7 vs 0%, P = 1.0%) between synthetic and biological mesh repair. CONCLUSION Biological meshes appear to be as effective as synthetic meshes in the short term for laparoscopic VMR. Mesh complication rates are low in both groups. Long-term follow-up is required to ascertain if these findings persist.
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Affiliation(s)
- N J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
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Mroczkowski P, Ortiz H, Penninckx F, Påhlman L. European quality assurance programme in rectal cancer--are we ready to launch? Colorectal Dis 2012; 14:960-6. [PMID: 21973222 DOI: 10.1111/j.1463-1318.2011.02845.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM There have been initiatives to create a European audit project. This paper addresses the issue of differences in data collected by different registries. METHOD Patients with rectal cancer treated in 2008 and recorded in quality registries from Belgium, Germany/Poland, Spain and Sweden were analyzed. The comparison included number of patients, gender, age, American Society of Anesthesiology (ASA) classification, preoperative diagnostic and staging procedures, neoadjuvant therapy, surgical treatment and quality of surgery, postoperative complications and adjuvant treatment. RESULTS The Belgian database consisted of 622 patients, the German/Polish database consisted of 3,393 patients, the Spanish database consisted of 1,641 patients and the Swedish database consisted of 1,826 patients. The percentage of patients in each ASA stage was highly variable. MRI use was highest in Spain and Sweden and very low in Germany/Poland. The percentage of cT4 stage tumours in Sweden was much higher than in all other countries. Sweden recorded the highest percentage of primary metastatic disease (20.3%) and Belgium recorded the lowest (10.2%). Neoadjuvant therapy in different protocols was administered to 41.2% patients in Germany/Poland, to 50.8% in Spain, to 55.2% in Belgium and to 62% in Sweden. Laparoscopic surgery (conversion rate) was performed for cure in 5% (28%) of patients in Sweden, in 20.8% (20.6%) in Spain, in 28.6% (15.2%) in Belgium and in 14.5% (8.9%) in Germany/Poland. The 30-day mortality for anterior resection, abdominoperineal excision and Hartmann's procedure in Sweden, Belgium and Spain was 2.0%, 2.3% and 3.1%, respectively. The German/Polish database reported an in-hospital mortality of 3.2%. CONCLUSION A European quality assurance project in rectal cancer is possible only after data collection is standardized.
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Affiliation(s)
- P Mroczkowski
- Department of General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany.
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Abstract
BACKGROUND Increased levels of secondary bile acids after cholecystectomy and cholelithiasis are believed to increase the risk of colorectal cancer, and several studies have suggested that the risk of colorectal cancer may be the greatest proximally. Numerous conflicting studies have been published and it remains unclear whether the risk is apparent in the rectum. This meta-analysis aims to determine the risk of developing rectal cancer following gallstone disease or cholecystectomy. METHODS The prospective protocol included a literature search of PubMed, MEDLINE, EMBASE, and Current Contents (1950-2011). Selection criteria were developed to sort for studies exploring the relationship between cholelithiasis, cholecystectomy, and rectal cancer in an adult population. A random-effects model was used to generate pooled odds ratios (OR) and 95% confidence intervals (CI). Publication bias and heterogeneity were assessed. RESULTS Of the 2358 studies identified, 42 were suitable for final analysis. There were 1,547,506 subjects in total, 14,226 diagnosed with rectal cancer, and 496,552 with gallstones or cholecystectomy. There was a statistically significant risk of rectal cancer following cholelithiasis (OR = 1.33; 95% CI = 1.02-1.73), though no risk was apparent following cholecystectomy (OR = 1.14; 95% CI = 0.92-1.41). CONCLUSIONS Cholelithiasis increases the risk of rectal cancer. No association exists between cholecystectomy and rectal cancer.
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Affiliation(s)
- Corinna Chiong
- Discipline of Surgery, The Whiteley-Martin Research Centre, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
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Abstract
BACKGROUND Innovative techniques created to restore gastrointestinal perineal continuity after abdominoperineal resection in patients with anorectal cancer include pseudocontinent perineal colostomy, in which the colon is pulled to the perineum and wrapped with a sleeve of stretched colon segment to act as a new sphincter. OBJECTIVE We investigated perineal reconstruction with a modified pseudocontinent perineal colostomy technique. DESIGN Prospective cohort study. SETTINGS Tertiary care university hospital in Egypt. PATIENTS Patients with T2 or T3 anorectal cancer invading the sphincter who underwent Miles abdominoperineal resection and immediate total pelvic reconstruction between 2003 and 2007. INTERVENTION Reconstruction consisted of a vertical rectus abdominis myocutaneous flap with modified perineal colostomy pulled through the flap to add the high-pressure zone of the flap to that of the colostomy and to create a persistent new anorectal angle. MAIN OUTCOME MEASURES Early and late complications were recorded. Functional results were evaluated at regular intervals by questionnaire, physical examination, and balloon manometry. Continence was graded according to Kirwan. Satisfaction with continence was assessed by questionnaire. RESULTS A total of 14 patients (3 women) were included. Tumors were adenocarcinoma (n = 11), squamous-cell carcinoma (n = 2), and melanoma (n = 1). Complete (R0) resection was achieved in all patients without perioperative deaths, major postoperative morbidity, or conversion to permanent iliac colostomy. Early postoperative complications (perineal wound infection, flap dehiscence, and partial perineal stoma necrosis) occurred in the first 4 patients. Late complications occurred in 7 patients, with mucosal prolapse in 3, stomal stricture in 4, and tumor recurrence in 1. Fecal continence progressed consistently with time, and by the end of the first year 8 patients (57%) had complete continence (grade A), 5 (36%) were continent with minor soiling (grade C), and 1 (7%) still had major soiling (grade D). After 6 months, 9 patients (64%) were satisfied with continence; after 1 year, 13 patients (93%) were satisfied. Regular enemas were necessary during the first year to improve soiling, and 8 patients (57%) were not in need after that. At 37 months median follow-up, 8 of 9 evaluable patients (89%) were satisfied with continence (grade A) without regular enemas. LIMITATIONS This was a preliminary observational study with no control group. CONCLUSIONS Total orthotopic pelvic reconstruction with autologous tissue transposition to rebuild the principle anorectal continence elements is feasible with minor complications, and is oncologically safe. This new technique offered high continence satisfaction independent of regular enemas and electrical stimulation.
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Affiliation(s)
- Omaya A H Nassar
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt.
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Augestad KM, Lindsetmo RO, Reynolds H, Stulberg J, Senagore A, Champagne B, Heriot AG, Leblanc F, Delaney CP. International trends in surgical treatment of rectal cancer. Am J Surg 2011; 201:353-7; discussion 357-8. [PMID: 21367378 DOI: 10.1016/j.amjsurg.2010.08.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 08/20/2010] [Accepted: 08/20/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described. METHODS We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers. RESULTS Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as "15 cm from the verge." Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001). CONCLUSIONS Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.
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Affiliation(s)
- Knut M Augestad
- Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, OH 44106-5047, USA
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Laparoscopic-assisted low anterior resection of the rectum--a review of the fascial composition in the pelvic space. Int J Colorectal Dis 2011; 26:405-14. [PMID: 21190027 DOI: 10.1007/s00384-010-1107-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Outcomes of rectal cancer treatment depend on the operative technique, and complication rates vary. Complications can occur during mobilization of the rectum, with damage to the ureter, autonomic nerves, and the rectum itself. Frequencies of these complications can be reduced by careful dissection of the correct tissue plane in the pelvic space. METHODOLOGY This paper reviews the fascial composition of the rectum for low anterior resection of the rectum. To date, fascial composition of the pelvic space has been considered based on clinical anatomy and histological examination of cadaveric specimens. However, clarification of fascial composition is clearly limited, to a certain extent, in histological examinations compared with clinical anatomy. CONCLUSIONS First, some degree of dissociation must exist between the histological examination and clinical anatomy. Second, surgeons should not consider fascia encountered intraoperatively as an artifact. To address these difficult issues, consideration should be made purely from the perspective of clinical anatomy. Originally, the trunk was embryologically regarded as a multi-layered structure (like an onion). Understanding the fascial composition of the abdomen is comparatively easy when approached from this perspective. If this theory is adapted to the pelvic space in order to avoid antilogy, an understanding of the fascial composition of the pelvic space should also be possible. We review previous papers based on this theory.
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Tjandra JJ, Chan MKY, Yeh HCH. Injectable silicone biomaterial (PTQ) is more effective than carbon-coated beads (Durasphere) in treating passive faecal incontinence--a randomized trial. Colorectal Dis 2009; 11:382-9. [PMID: 18637935 DOI: 10.1111/j.1463-1318.2008.01634.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Both injectable silicone biomaterial (PTQ) and pyrolytic carbon-coated beads (Durasphere) have been shown to be effective in treating passive faecal incontinence due to internal sphincter dysfunction. This is a randomized study to evaluate their relative safety and efficacy. METHOD Forty patients (mean age 59.5 years vs 58.9 years) were randomized to have inter-sphincteric injection of PTQ or submucosal injection of Durasphere. Patients were assessed with anorectal physiology, endoanal ultrasound, a validated incontinence score and quality of life questionnaires. RESULTS In the Durasphere group, complications included rectal pain (5%), erosion through rectal mucosa (10%), and type III hypersensitivity reaction (5%). No complications occurred in the PTQ group. Compared with PTQ, Durasphere group has a more rapid action, with improved continence at 2 weeks after injection. In both groups, faecal continence significantly improved 6 weeks after injection, and continued to improve significantly up to 6 months in both groups (P < 0.0001). At 6 weeks, 6 and 12 months after injection, significantly more PTQ patients achieved greater than 50% improvement in Wexner's continence score than Durasphere patients (respectively, P = 0.01; P < 0.0001; P = 0.001). There was a significant improvement in faecal incontinence quality of life scale and the 12-month physical health scale of Short Form-12 health survey in the PTQ group but not in the Durasphere group. CONCLUSION In patients with internal sphincter dysfunction, injectable silicone biomaterial was safer and more effective than Durasphere.
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Affiliation(s)
- J J Tjandra
- Department of Colorectal Surgery, Epworth Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Sacral nerve stimulation for fecal incontinence: external anal sphincter defect vs. intact anal sphincter. Dis Colon Rectum 2008; 51:1015-24; discussion 1024-5. [PMID: 18484136 DOI: 10.1007/s10350-008-9326-0] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 11/18/2007] [Accepted: 12/18/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This prospective study was designed to assess the effectiveness of sacral nerve stimulation for fecal incontinence in patients with external anal sphincter defect and to evaluate its efficacy regarding presence and size of sphincter defect. METHODS Fifty-three consecutive patients who underwent sacral nerve stimulation for fecal incontinence were divided into two groups: external anal sphincter defect group (n = 21) vs. intact sphincter group (n = 32). Follow-up was performed at 3, 6, and 12 months with anorectal physiology, Wexner's score, bowel diary, and quality of life questionnaires. RESULTS The external anal sphincter defect group (defect <90 degrees:defect 90 degrees-120 degrees = 11:10) and intact sphincter group were comparable with regard to age (mean, 63 vs. 63.6) and sex. Incidence of internal anal sphincter defect and pudendal neuropathy was similar. All 53 patients benefited from sacral nerve stimulation. Weekly incontinent episodes decreased from 13.8 to 5 (P < 0.0001) for patients with external anal sphincter defects and from 6.7 to 2 (P = 0.001) for patients with intact sphincter at 12-month follow-up. Quality of life scores improved in both groups (P < 0.0125). There was no significant difference in improvement in functional outcomes after sacral nerve stimulation between patients with or without external anal sphincter defects. Clinical benefit of sacral nerve stimulation was similar among patients with external anal sphincter defects, irrespective of its size. Presence of pudendal neuropathy did not affect outcome of neurostimulation. CONCLUSIONS Sacral nerve stimulation for fecal incontinence is as effective in patients with external anal sphincter defects as those with intact sphincter and the result is similar for defect size up to 120 degrees of circumference.
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Tjandra JJ, Chan MKY, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum 2008; 51:494-502. [PMID: 18278532 DOI: 10.1007/s10350-007-9103-5] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 05/29/2007] [Accepted: 06/19/2007] [Indexed: 01/22/2023]
Abstract
PURPOSE This randomized study was designed to compare the effect of sacral neuromodulation with optimal medical therapy in patients with severe fecal incontinence. METHODS Patients (aged 39-86 years) with severe fecal incontinence were randomized to have sacral nerve stimulation (SNS group; n = 60) or best supportive therapy (control; n = 60), which consisted of pelvic floor exercises, bulking agent, and dietary manipulation. Full assessment included endoanal ultrasound, anorectal physiology, two-week bowel diary, and fecal incontinence quality of life index. The follow-up duration was 12 months. RESULTS The sacral nerve stimulation group was similar to the control group with regard to gender (F:M = 11:1 vs. 14:1) and age (mean, 63.9 vs. 63 years). The incidence of a defect of < or = 120 degrees of the external anal sphincter and pudendal neuropathy was similar between the groups. Trial screening improved incontinent episodes by more than 50 percent in 54 patients (90 percent). Full-stage sacral nerve stimulation was performed in 53 of these 54 "successful" patients. There were no septic complications. With sacral nerve stimulation, mean incontinent episodes per week decreased from 9.5 to 3.1 (P < 0.0001) and mean incontinent days per week from 3.3 to 1 (P < 0.0001). Perfect continence was accomplished in 25 patients (47.2 percent). In the sacral nerve stimulation group, there was a significant (P < 0.0001) improvement in fecal incontinence quality of life index in all four domains. By contrast, there was no significant improvement in fecal continence and the fecal incontinence quality of life scores in the control group. CONCLUSIONS Sacral neuromodulation significantly improved the outcome in patients with severe fecal incontinence compared with the control group undergoing optimal medical therapy.
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Affiliation(s)
- Joe J Tjandra
- Department of Colorectal Surgery, Epworth Hospital, University of Melbourne, Melbourne, Australia
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Bader FG, Bouchard R, Lubienski A, Keller R, Mirow L, Czymek R, Habermann JK, Bruch HP, Roblick UJ. [Progress in diagnostics of anorectal disorders. Part II: radiology]. Chirurg 2008; 79:410-7. [PMID: 18418564 DOI: 10.1007/s00104-008-1544-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.
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Affiliation(s)
- F G Bader
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburgerallee 160, 23538 Lübeck
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Tjandra JJ, Tan JJY, Lim JF, Murray-Green C, Kennedy ML, Lubowski DZ. Rectogesic (glyceryl trinitrate 0.2%) ointment relieves symptoms of haemorrhoids associated with high resting anal canal pressures. Colorectal Dis 2007; 9:457-63. [PMID: 17504344 DOI: 10.1111/j.1463-1318.2006.01134.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Some haemorrhoids are associated with high resting anal canal pressures. The aim of this study was to assess if Rectogesic, a topical glyceryl trinitrate 0.2% ointment was effective in relieving symptoms of early grade haemorrhoids associated with high resting anal canal pressures. METHOD This was a prospective, two-centre, open label study of 58 patients with persistent haemorrhoidal symptoms. Patients with first or second degree haemorrhoids and a maximum resting anal canal pressure > 70 mmHg were included. Rectogesic was applied three times a day for 14 days. Anorectal manometry was performed 30 min after the first application of Rectogesic. A 28-day diary was completed during 14 days of therapy and for 14 days after cessation of treatment. This recorded the incidence of rectal bleeding, and visual analogue scales for anal pain, throbbing, pruritus, irritation and difficulty in bowel movement. RESULTS Maximum resting anal canal pressures were reduced after application of Rectogesic (115.0 +/- 40.4 mmHg vs 94.7 +/- 34.1 mmHg, P < 0.001). In the study period and at 14 days after cessation of Rectogesic, there was significant reduction in rectal bleeding (P = 0.0002), and significant improvement of anal pain (P = 0.0024), throbbing (P = 0.0355), pruritus (P = 0.0043), irritation (P = 0.0000) and difficulty in bowel movement (P = 0.001). The main adverse event was headache in 43.1% of patients. CONCLUSION Rectogesic is a safe and feasible treatment for patients with early grade haemorrhoids associated with high resting anal canal pressures.
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Affiliation(s)
- J J Tjandra
- Department of Colorectal Surgery, Epworth Colorectal Center and The Royal Melbourne Hospital, Melbourne, Australia.
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Tjandra JJ, Lim JF, Hiscock R, Rajendra P. Injectable silicone biomaterial for fecal incontinence caused by internal anal sphincter dysfunction is effective. Dis Colon Rectum 2004; 47:2138-46. [PMID: 15657666 DOI: 10.1007/s10350-004-0760-3] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Fecal incontinence caused by a weak or disrupted internal anal sphincter is common but there has been no effective treatment. This prospective study evaluates the medium-term clinical effects of an injectable silicone biomaterial, PTP (Bioplastique), used to augment the internal anal sphincter. METHOD Eighty-two patients (64 females; median age, 66 years) with severe fecal incontinence and a low anal resting pressure caused by internal anal sphincter dysfunction (defect, n = 11; intact, n = 71) were randomized to PTP injection into intersphincteric space and internal anal sphincter with (Group A, n = 42) or without (Group B, n = 40) guidance by endoanal ultrasound. Both groups were similar in terms of age, gender, past anorectal surgery, duration of follow-up (median, 6 months; range, 1-12 months), and baseline continence score. Sixty-two percent of Group A and 55 percent of Group B had prolonged pudendal nerve terminal motor latency. RESULTS There was no significant complication. Two patients in Group A and four patients in Group B noted minor discomfort at injection sites. At one month postprocedure, endoanal ultrasound confirmed retention of silicone biomaterial without migration. In both groups, fecal continence was significantly improved by PTP implants 1 month after injection, but continued to improve significantly for up to 12 months in Group A and 6 months in Group B (P < 0.001). Improvement in fecal continence and maximum anal resting pressure was significantly greater in Group A, in whom injection was guided by endoanal ultrasound, than in Group B. At three months after injection, significantly more Group A patients than Group B patients achieved >50 percent improvement in Wexner's continence score (69 percent vs. 40 percent; P = 0.014). Ninety-three percent of Group A and 92 percent of Group B had >50 percent improvement in global quality of life scores (visual analog scale). At a median follow-up of 6 months, all domains of the fecal incontinence quality of life scale improved significantly in both groups; however, the physical function and mental health scores of Short Form-12 only improved in Group A. A prolonged pudendal nerve terminal motor latency had no effect on functional outcome in either group. CONCLUSION Injection of silicone biomaterial provided a marked improvement in fecal continence and quality of life in patients with internal sphincter dysfunction, despite the presence of pudendal neuropathy.
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Affiliation(s)
- J J Tjandra
- Department of Colorectal Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.
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