Introduction

Rectum carcinoma grows relatively slowly and behaves more favourably than other gastroenteric neoplasias [1]. These biologic features are also often observed in lymph nodal and hepatic metastases [2]. Among the ways of spreading, haematogenous is the most belated, whereas lymphatic is the most precocious [3]. Most patients (65-80%) have shown that their illness has primarily spread around the rectal wall (T3N0M0), and/or involving the mesorectal lymph nodes (N1-2M0), which is a manifestation that represents a stage of locoregional illness [4]. Therefore, for most of its natural history, surgical therapy has an important role in the treatment of rectal cancer [1, 5].

The oncological premises of rectum resective surgery have been known for almost a century, that is since Miles [6] and Moyniham [7] recognised the importance of the anatomy of the lymphatic drainage system as a guide to the extension of a proper exeresis of the cancer.

However, the application of these principles in clinical practice has varied greatly. The "optimal" surgical treatment of rectal cancer is yet to be studied in its entirety, and there is no unanimous agreement about the extension to be given to lymphadenectomy [8, 9]. While for some surgeons an extended lymphatic exeresis means performing a high ligation of the inferior mesenteric artery associating it with the mesenteric lymphadenectomy, for others it is configured with the complete removal of the retroperi-toneal lymphatic tissue [5].

Western surgeons consider the mesorectum as the main way rectum carcinoma spreads [10,11, 12], and its complete removal (total mesorectal excision (TME)) as necessary and sufficient for radical surgical treatment of rectal cancer [1,4,13].

Japanese surgeons are very careful to prevent the extramesorectal spread to lateral pelvic lymph nodes [2,14], which may be found in 10-25% of rectal neo-plasia localised underneath the peritoneal reflection [2, 3, 12]. Because such lateral spread verifies and exceeds the limits identified by Quirke within the margin of circumferential resection [15], it would be necessary, according to Japanese surgeons, to perform the extension of lymphadenectomy to the nodal pelvic iliac-obturator stations (lateral pelvic lymph node dissection (LPLD)) [2, 3,14].

This "ultra-radical" surgery, although it is convenient in terms of local relapses and long-term survival compared with more limited lymphectomies [3, 14], is burdened with a high percentage of genito-urinary disturbances [16]. These functional consequences, together with evidence of local and long-term tumour control after performing TME without using LPLD, which are just favourable as those obtained with LPLD [4, 11], did not favour the acceptance of LPLD in Europe and in the United States; also considering the "Western" point of view which interprets the metastasisation of lateral pelvic lymph nodes as no longer a regional but a systemic illness, which must then be treated using (neo)adjuvant ra-diochemotherapy strategies [4,10].

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