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...

Operation

The operation is performed under general anaesthesia. The patient is placed in the dependent position, as described during the pre-operative examination. The most difficult position is the prone position. This position, for tumours of the anterior wall, requires strong support of the hips and chest so the abdomen itself is mobile. When the lateral Simms position is necessary, it is important that the anus is accessible and the table or legs of the patient do not impede mobility of 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

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...

Transanal Polypectomy

The operating anoscope Fig. 1 is introduced and the polyp is identified. The base of the polyp is infiltrated with a weak epinephrine solution 1 300 000 so that the mucosa is lifted off the submucosa. A 1-cm margin around the polyp is included in the excision, particularly for villous lesions, so that the entire mucosa and polypoidal lesion are excised, leaving a bare rectal wall at the base. A polyp that cannot be easily excised in the plane suggests malignant invasion, in which case the...

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...

Rectal Anatomy

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...