Transposition of the Gracilis Muscle

On the basis of anatomical and clinical studies on the vascular supply to the gracilis muscle, Williams advocated interruption of distal small arteries to the gracilis muscle 4 weeks before the muscle transposition to enhance the intramuscular anastomosis and prevent necrosis 22 , but this is not considered mandatory by other Authors (like Baeten and Cav-ina) based on their large clinical experience. The patient is placed in a modified Lloyd-Davis position with the dominant leg abducted and...

Rectal Cancer Staging

ERUS criteria to determine the depth of tumour invasion, based on the classification proposed by Hildebrandt and Feifel 3 , are as follows (a) uT0 (benign lesion) the mucosal layer is expanded but the third hyperechoic submucosal layer remains intact around the entire breadth of the tumour (b) uT1 (submucosal cancer) the hyperechoic submucosal layer is Fig. 8a, b. Normal ultrasound anatomy of the anal sphincter in 2D (a) and 3D (b) Fig. 8a, b. Normal ultrasound anatomy of the anal sphincter in...

Ligation of Vascular Pedicle

The mobilised sigmoid colon is retracted anteriorly and laterally. The vascular pedicle is divided from the fascia covering aorta. In this connection, it is necessary to identify superior hypogastric plexus and leave it on the fascia. Upon division of the vascular pedicle up to the area where the a. mesenteric inferior (IMA) takes off the aorta, surgeons should be very careful with the left branch of sympathetic pre-aortic trunk, as the pedicle is closely adjoined to it over a length of 2-3 cm....

Surgical Options

Provenzale et al. 9 proposed prophylactic colectomy for patients with a long-standing colitis or at risk of developing CRC this approach should prevent the need of emergency colectomy. In a comparative study of about 17 different strategies, including no colonoscopic surveillance, surveillance at varying intervals and prophylactic proctocolectomy with ileal pouch-anal anastomosis, Provenzale showed that for a 30-year-old patient with pancolitis for 10 years, prophylactic colectomy would...

Technique

Endoluminal ultrasound is usually performed with the patient in the left lateral decubitus position. Before the probe is inserted into the rectum, a digital rectal examination may be performed to identify the size, fixation, morphology and location of the tumour, if it is low enough. If there is a stenotic annular lesion, the finger can check to determine whether it will allow easy passage of the probe. The entire shaft of the probe is coated with a thin layer of warm gel using a paper towel....

Electrostimulation Technique

Electrostimulation can be started 2-4 weeks after the operation, when the perineal wounds have healed and the gracilis tendon is firmly sealed to the ischiat-ic bone. The electrical parameters can be programmed by a portable tele-neuroprogrammer (N-vision MEDTRONIC) according to two different protocols 25 . a. Continuous electrostimulation impulse width 210 ms, minimum voltage required for the full muscle contraction, increased frequency from 2 Hz for the first and second week, to 5 Hz for the...

Diagnosis of Local Recurrence

The early detection of local recurrence is one of the main goals of follow-up. Most relapses, when discovered, are either locally extensive or widespread disseminated, and occur, as mentioned, within a 2-year period from the initial curative operation. However, a small number of patients are in good general shape, with a surgically resectable recurrence, offering a chance for potentially curative resection. Early detection of the local recurrence can be achieved by a combination of history,...

Ultrasound Anatomy

On ultrasound the normal rectal wall is 2-3 mm thick and is composed of a five-layer structure 2 (Fig. 6). The first hyperechoic layer corresponds to the interface of the balloon with the rectal mucosal surface, the second hypoechoic layer to the mucosa and mus-colaris mucosa, the third hyperechoic layer to the submucosa, the fourth hypoechoic layer to the mus-colaris propria and the fifth hyperechoic layer to the Fig. 6. Bidimensional ultrasonographic five-layer structure of the normal rectal...

Transsphincteric Approach [3

Most higher rectal lesions would be treated today by total rectal excision and a low anterior resection or colo-anal anastomosis. Nevertheless, in a few selected cases trans-sphincteric excision may be useful. The patient is placed in an appropriate position, depending on the localisation of the tumour. We made a parasacral incision caudally. The peripheral aspect of the incision is deepened to identify the lower fibres of gluteus maximus. Then the somatic and visceral musculature around the...

Magnetic Resonance Imaging

The successful introduction of magnetic resonance imaging (MRI) for pelvic diseases has, in recent years, led to the gradual replacement of CT by MRI for local and regional rectal cancer staging. Initial MR studies were performed with a body coil. Because conventional body coil techniques showed a resolution that was still insufficient to differentiate the individual layers of the rectal wall, overall accuracies reported for MRI with a body coil have not been any better than those reported for...

Lateral Pelvic Lymph Node Dissection LPLD Technical Notes Indications Results and Complications

LPLD consists of a complete dissection of the endopelvic fascia together with the rectum and mesorectum 9 the first phase is represented by the complete removal of the para-aortic and paracaval tissues, from the left renal vein, up to the aorto-caval bifurcation. Starting then from the aorto-caval bifurcation, and using ureters as lateral dissection limits, all lymph nodes as well as the lymphatic-cellular tissue are removed medially to the common and internal iliac vessels 5, 9 . Moreover, the...

Sphincter Preservation

After pre-operative RT, as shown, tumour is often reduced in size, is downstaged or even shrinks and sometimes also disappears and therefore may facilitate conservative surgery. Data from the literature are not conclusive with respect to how often a planned abdominoperineal resection can be converted to a sphincter-saving surgery after pre-operative radiochemotherapy. It depends also on the specialisation of the surgeon, techniques used in colo-anal anastomoses, intersphincteric resections and...

Pre Operative Therapy

Locally advanced colorectal cancer poses a difficult problem for surgeons, oncologists and radiotherapists in terms of patient survival and quality of life. In fact, median survival times after palliative resection are about 10 months, during which time the patient is usually invalid. Around 1990, many random clinical studies showed a significant increase in disease-free survival times in patients undergoing radical curative resection when combined with radio- and chemotherapy 2, 3 . It has...

How to Test QoL

In the recent past, there was diffuse scepticism among researchers on using QoL tests in their trials or a trend towards using non-standardised questionnaires 14 . The former is due to the high number of methods for testing QoL by interviews (structured, semi-structured, non-structured), by questionnaires (standardised, non-standardised) and by ad hoc questions. Theoretically speaking, most of them can be easily and efficiently used in clinical practice but as already explained, cannot be...

Stage uT0 Villous Adenoma

Sonographic evaluation of a villous rectal lesion is helpful in determining the presence of tumour invasion. The presence of an intact hyperechoic submu-cosal interface indicates lack of tumour invasion into the submucosa. Heintz et al. 4 believe that ERUS cannot differentiate between villous adenoma and invasive cancers because neither the muscolaris mucosae nor the submucosa is sonographically definable and the first hypoechoic layer corresponds anatomically with the mucosa and the submucosa....

Spirio And Virgo Relationship

Pfister DG, Horwitz RI (1987) The rightward shift of colon cancer. Aging or artifact J Clin Gastroenterol 9 58-61 2. Nelson RL (1998) Division of the colorectum into anatomic subsites why and where J Surg Oncol 69 1-3 3. Parkin DM, Pisani P, Ferlay J (1999) Global cancer statistics. CA Cancer J Clin 49 33-64 4. Nakaji S, Umeda T, Shimoyama T et al (2003) Environmental factors affect colon carcinoma and rectal carcinoma in men and women differently. Int J Colorectal Dis 18 481-486 5. Gatta G,...

Post Operative Radiation Therapy

In our institution, we rarely perform post-operative radiation therapy, which is frequently associated with 5-fluorouracil (5-FU)-based chemotherapy and is delivered when the surgical specimen of a good patient selected for exclusive surgery shows risks of local recurrence such as incomplete tumour resection as well as nodal disease involvement. Post-operative radiotherapy has shown the advantage of being selectively delivered in patients at high risk of local recurrence as well as the...

Contents

Epidemiology and Burden of Disease Stefano Tardivo, William Mantovani, Emanuele Torri, Albino Poli 1 Diagnostic Imaging Diagnosis and Staging Riccardo Manfredi, Giulia Zamboni, Giovanni Carbognin, Farah Moore, Rossella Pre-Operative Staging Endorectal Ultrasound Giulio Aniello Santoro, Carlo Predictive Markers in Physiology and Anatomy for Outcomes in Rectal Cancer Patients Johann Rectal Cancer Pathological Features and their Relationship to Prognosis and Treatment Paola Capelli,...

References

Parkin DM, Bray F, Ferlay J, Pisani P (2005) Global cancer statistics, 2002. CA Cancer J Clin 55 74-108 2. Miles WE (1908) Method for performing abdomin-operineal excision for carcinoma of the rectum and the terminal portion of the pelvic colon. Lancet 2 1812-1813 3. Dixon CF (1939) Surgical removal of lesions occurring in the sigmoid or the rectosigmoid. Am J Surg 46 12-17 4. Heald RJ (1988) The 'Holy Plane' of rectal surgery. J R Soc Med 81 503-508 5. Szczepkowski M (2002) Do we still need a...

Indications and Contraindications in Surgical Therapy

Nccn Guideline Renal Mass

The indications for resection of hepatic metastases are obtained from the analysis of the prognostic elements described above. The pre-operative evaluation of the patient should consider general examinations for abdominal general surgery and evaluation of liver function 36 . In patients with normal liver function, resections of 70-80 of the total hepatic mass can be safely performed. In patients submitted to per-oper-ative chemotherapy or with chronic liver disease, resection should be limited...

Materials and Methods

Between 1999 and 2003 we carried out a total anorectal reconstruction (TAR) in 12 patients previously operated on with an APR by performing a perineal colostomy and placing an artificial bowel sphincter around the perineal stoma 20, 21 . This procedure was performed by three surgeons in different institutions according to a common protocol. Ten patients had been operated on for rectal cancer, one had had a colostomy in childhood for rectal agenesia and one patient had been treated with a Miles...

Stage uT2 Invasion of the Muscular Layer

Sonographic diagnosis of tumour invasion of the muscolaris propria is based on thickening of this layer (Fig. 13). The muscolaris propria is represented by a thin hypoechoic layer adjacent to the hypere-choic submucosal interface. As the tumour is also hypoechoic, early muscular invasion is difficult to Fig. 13a, b. uT2 rectal tumour in 2D (a) and 3D (b) Fig. 13a, b. uT2 rectal tumour in 2D (a) and 3D (b) Fig. 14a, b. uT3 rectal tumour in 2D (a) and 3D (b) Fig. 14a, b. uT3 rectal tumour in 2D...

Avoidable Risk Factors

A comparison of CRC rates in different countries shows great variation. And time trends within some countries are also notable. Dietary, lifestyle and environmental factors but not racial, ethnical or genetic factors seem to account for a great part of the differences in incidence. Some of the most striking, rapid and well documented changes in diet were seen in Japan 93 . Consumption of meat and dairy products increased between the 1950s and 1990s and thus the rate of CRC 4 . Changes in food...

Non Avoidable Risk Factors

Certain differences in sex incidence emerge when carcinomas are assessed separately for the large bewed. Right colon lesions have been observed to be more common in women while men seem to be at higher risk for rectal cancer. The prevalence of colon cancer has a ratio of females males equal to 1.2 1, and rectal cancer a ratio of males females equal to 1.4 1. Right colon cancers have been shown to account for a greater percentage of colorectal neoplasms in older patients while left colon and...

Stage uT1 Submucosal Invasion

Haggitt Levels

If a tumour arises in a polyp it is important to determine whether the stalk is invaded. Differences in classification are reported between Western and Japanese pathologists. In 1985 Haggitt et al. 6 divid Fig. 9. uT0 rectal tumour (villous adenoma) in 2D (a) and 3D (b) Fig. 9. uT0 rectal tumour (villous adenoma) in 2D (a) and 3D (b) Fig. 10. Level of submucosal invasion according to Haggitt's Fig. 11. Level of submucosal invasion according to the classification Japanese classification Fig. 10....

Early and Late Complications After LAR

Anastomotic leakage has always been a major clinical problem in rectal or anal anastomosis, however this complication after LAR still remains a challenging clinical problem that can lead to significant morbidity and mortality. The use of stapling devices, performing mid and low rectal cancer resections with TME that require radical dissection may lead to a higher rate of anastomotic leakage. The reported clinical leakage rate after anterior resection varies from 3 to 21 depending on the level...

Splenic Flexure Take Down

A hole is made in the distal part of the mesentery of the transverse colon, above the tail of the pancreas Figs. 16,17 . This allows a flow of gas into the lesser sac and thus facilitates the separation of the omen-tum from the colon, which is taken down from the middle third of the transverse colon Fig. 18 . The assistant surgeon helps by pulling the transverse colon towards the pelvis with a grasper introduced in the left flank. The splenic flexure is then carefully detached from the spleen...

Handsewn Colo Anal Anastomosis with Mucosectomy

This technique, described by Parks in 1982 12,13 , is performed with a perineal approach. Once the anal canal has been exposed with a Lone Star type retractor, rectal mucosa is infiltrated with an adrenaline solution, favouring dissection and haemostasis. Mucosectomy is then performed starting a few millimetres above the dentate line up to the apex of the rectal stump. The anastomosis is then sutured between the colon or the apex of the colonic reservoir, pulled down to the rectal muscular...

Contributors

Sezione di Chirurgia Generale e Trapianto Francesco Bianco 1st Department of Surgery S.G. Moscati Hospital Avellino, Italy Department of Colorectal and Proctologic Surgery Department of General Surgery Santa Croce e Carle Hospital Cuneo, Italy Laura Bortesi Department of Pathology Policlinico G. B. Rossi Verona, Italy Maurizio Cantore Department of Oncology Hospital of Massa-Carrara Carrara, Italy Paola Capelli Department of Pathology Policlinico G. B. Rossi Verona, Italy Giovanni Carbognin...

Rectal Anatomy

What Houston Valv Rectum

The analysis of the anatomy of the distal portion of the large intestine and of the sigmoid colon at the level of the third sacral vertebra is continuous with the distal portion of the large intestine the rectum. The longitudinal musculature that at the colonic level is arranged in three bands, the taeniae, at the colorectal junction expands again to form a continuous layer of longitudinal musculature 1 . The haus-tra disappear and the distal portion of the intestine appears as a smooth, almost...