Intersphincteric Resection for Low Rectal Tumors

182 Pages·2012·9.025 MB·English

by  Barna Bogner MD (auth.), Prof. Rudolf Schiessel MD, Univ.-Doz. Peter Metzger MD, PhD (eds.)

~ SpringerWienNewYork
Rudolf Schiessel
Peter Metzger
Editors
Intersphincteric Resection
for Low Rectal Tumors
SpringerWienNewYork
Prof. Rudolf Schiessel,MD
LudwigBoltzmannInstituteforSurgicalOncology,Vienna,Austria
Univ.-Doz.PeterMetzger, MD, PhD
DanubeHospital,SurgicalDepartment,Vienna,Austria
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Preface
Patientswithrectalcancerexpectfromtheirdoctorscure rectum.Thedevelopmentofcircularstaplinginstruments
fromthedisease.Anothergoalistokeeptheintegrityof enabledlowrectalanastomoses.Butevenwithlowante-
theirbodyintact.Veryoftenthefirstquestionofapatient riorresectionpatientswithtumorsofthelowerthirdofthe
willbe:“DoIneedastoma?”Weknowthatmostpeople rectum, not invading the sphincter apparatus are very
areworriedbytheannouncementthatapermanentstoma often treated by abdominoperineal resection, thereby
mightbeinevitable.Theacceptanceofapermanentstoma sacrifizingahealthysphincterapparatus.Thisisdonein
is higher in northern than in southern Europe, low in thefearofanunradicaltumorresectionandbecauseofthe
islamic countries andineastern Asia. technical difficulties which are common in the lower
Theresponsibilityofthesurgeonistomeettwogoals: rectum especially in obese males. The authors of this
1. To cure the cancer and 2. To save sphincter function. bookwillsharetheirexperiencewithyouinthetreatment
Thedevelopmentofrectalsurgeryhasshownthatinthe oftumorsofthelowerrectumapplyinglatestadvancesin
early days the surgeons developed methods to avoid diagnostic and therapeuticmeasures.
laparotomy because survival of the operation was the With a coded link you can watch videos showing the
dominating goal. Later more radical procedures took technique of:
place and for a long time abdominoperineal resection
1. R.Schiessel:Intersphinctericresectionforlowrectal
becamethestandardprocedure.Thegrowingknowledge
tumors:Theopen technique
aboutthelymphaticspreadofrectalcancerandthefurther
2. P.Metzger,M.Hoffmann,R.Schiessel:Laparoscopic
development of the surgical techniques opened the field
techniqueofintersphinctericresectionforlowrectal
for sphincter saving surgery. But anterior resection of
tumors
rectalcancerswasmainlyappliedtotumorsoftheupper
3. Seon-Hahn Kim: Robot assisted intersphincteric
thirdoftherectum.Thereasonwasanoverestimationof
resection
thelongitudinalspreadofrectaltumors.Adistalresection
marginwithaminimumof3cmormorewastherule.This Weareproud,thatsomanyinternationalexpertshave
precluded many cases in the middle and lower rectum agreed to contribute to this book and we hope that this
from sphincter salvage. A meticulous analysis of cases bookwillhelpoursurgicalcolleaguesintheirdecisions.
with different distal margins showed that margins up to
1cmdonotincreaselocalrecurrence.Thereforesphincter RudolfSchiessel
savingsurgerycouldbeextendedtothemiddlethirdofthe PeterMetzger
Contents
Pathology of low rectal cancer Endoanalultrasound:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 19
EAUSforanalcanalneoplasms[5] :::::::::::::::::::::::::::::::::: 20
The pathological assessmentof the surgical Primarytumor(T)::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 20
Regionalnodes(N):::::::::::::::::::::::::::::::::::::::::::::::::::::::: 20
specimens originating fromthe lower rectum
Distantmetastasis:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 20
and anal canal::::::::::::::::::::::::::::::::::::::::::::::::::::::: 3 Stagegrouping:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 21
BarnaBogner Conclusions::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 21
Developmentandanatomyoftheanorectalwalland Intersphincteric resection: MRI for staging::::::: 25
surroundingstructures::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 3
MichaelUrban
Thepathologicalinvestigationandstagingofthelower
rectal/analcanalcancers:::::::::::::::::::::::::::::::::::::::::::::::::::::: 5
ThedefinitionsofthesurgicalplanesafterTME:::::::::::::::: 6 Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 25
Examinationtechnique:::::::::::::::::::::::::::::::::::::::::::::::::::::: 25
Therateofcircumferentialmargin(CRM)
involvement/Rstatus::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 6 Anatomicalconsiderations::::::::::::::::::::::::::::::::::::::::::::::::: 26
Theusefulnessoflargehistologicalsections:::::::::::::::::::::::: 7 Theperitonealreflection:::::::::::::::::::::::::::::::::::::::::::::::: 26
TheTNMstageofthelowerrectum/analcanalcancers:::::::: 7 Theurogenitalseptum::::::::::::::::::::::::::::::::::::::::::::::::::: 27
Thepelvicnerveplexuses:::::::::::::::::::::::::::::::::::::::::::::: 28
Theriskfactorsforrecurrenceafterintersphincteric
resection::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 8 Themesorectumandmesorectalfascia::::::::::::::::::::::::::: 28
Thenormalrectalwall::::::::::::::::::::::::::::::::::::::::::::::::::: 28
Thehistologicalconsequencesofneoadjuvant
chemoradiotherapy(CRT)intheanalcomplex::::::::::::::::::::: 8 Thepelvicfloorandanalsphincter::::::::::::::::::::::::::::::::: 29
TumormorphologyandTstaging:::::::::::::::::::::::::::::::::::::: 29
Polypoidaltumors:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 31
Mucinoustumors::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 32
Preoperative diagnostic procedures Stagingofrectaltumors::::::::::::::::::::::::::::::::::::::::::::::::: 33
ImageinterpretationcriteriaforTstaging::::::::::::::::::: 33
Endorectal ultrasound for preoperative Lymphnodestaging::::::::::::::::::::::::::::::::::::::::::::::::::: 33
Venousspread:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 34
staging::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 13
Thecircumferentialresectionmargin
BryanLoh,MartinR.Weiser,andW.DouglasWongy inrectalcancer:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 35
Sphincterinfiltration:::::::::::::::::::::::::::::::::::::::::::::::::::::: 35
Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 13 Futuredevelopments:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 36
Stagingofrectalcancer::::::::::::::::::::::::::::::::::::::::::::::::::::: 13 MovingtableMRI:::::::::::::::::::::::::::::::::::::::::::::::::: 36
TNMstagingsystemforrectalcancer ::::::::::::::::::::::::::::::: 13 Diffusionweightedimaging:::::::::::::::::::::::::::::::::::: 37
Primarytumor(T)::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 13 MRIafterneoadjuvanttherapy::::::::::::::::::::::::::::::::::::::::::: 37
Regionallymphnodes(N)::::::::::::::::::::::::::::::::::::::::::::: 13 Conclusion:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 38
Metastases(M):::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 14
Stagegrouping:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 14
MSKCCmodifiedERUSstagingsystem:::::::::::::::::::::::: 14
Equipmentandtechnique::::::::::::::::::::::::::::::::::::::::::::::::::: 14 Preoperative therapeutic options
NormalERUSanatomy::::::::::::::::::::::::::::::::::::::::::::::::::::: 14
Assessmentofrectalneoplasms::::::::::::::::::::::::::::::::::::::::: 15 Selective non-operative management of distal
uT0lesions:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 15
uT1lesions:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 15 rectal cancer: The Watch & Wait Protocol::::::::: 43
uT2lesions:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 16 AngelitaHabr-Gama,RodrigoO.Perez,PatricioB.Lynn,
uT3lesions:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 16 GuilhermePaginS~aoJuli~ao,and
uT4lesions:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 16 JoaquimJos(cid:2)eGamaRodrigues
Nodalinvolvement:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 17
Accuracyofultrasoundindiagnosisofrectalcancer:::::::::: 18 Rationaleforanon-immediatesurgicalapproach::::::::::::::: 43
ERUSinpostoperativefollow-up::::::::::::::::::::::::::::::::::::::: 19 Responseassessment::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 43
viii Contents
Clinicalassessment:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 44 Diagnosticprocedures::::::::::::::::::::::::::::::::::::::::::::::::::::::: 74
Radiologicalstudies:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 45 Endoscopyandbiopsy::::::::::::::::::::::::::::::::::::::::::::::::::: 74
CEA::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 46 Magneticresonanceimaging:::::::::::::::::::::::::::::::::::::::::: 75
EndoscopicbiopsiesafterCRT:::::::::::::::::::::::::::::::::::::::::: 46 Endosonographyoftherectum::::::::::::::::::::::::::::::::::::::: 75
FactorsassociatedwithtumorresponseafterCRT:::::::::::::: 46 Otherimaging::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 75
Chemoradiationregimen:::::::::::::::::::::::::::::::::::::::::::::::::::: 46 Sphinctermanometry::::::::::::::::::::::::::::::::::::::::::::::::::::: 75
Timefortumorresponseassessment:::::::::::::::::::::::::::::::::: 47 Planningofsurgery:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 76
Tumorfeaturesandbiology::::::::::::::::::::::::::::::::::::::::::::::: 48 Theoperation:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 76
TheWatch&WaitProtocol::::::::::::::::::::::::::::::::::::::::::::::: 49 Instruments:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 76
Results:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 49 Positioningofthepatient::::::::::::::::::::::::::::::::::::::::::::::: 76
Evolution:Theextendedchemoradiotherapyregimen::::::::: 50 Positioningofthesurgicalteam::::::::::::::::::::::::::::::::::::: 77
Perspectives:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 50 Surgicaltechnique::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 77
Abdominalpart:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 77
Perinealpart:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 79
Postoperativecare:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 81
Surgery of low rectal cancer: Results:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 81
Indications::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 82
Intersphincteric resection
Complications::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 82
and its modifications Oncologicalresults:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 83
Functionalresults::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 83
Conclusion:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 83
Surgicalanatomy in intersphincteric
resection:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 57
The laparoscopic technique of intersphincteric
YusukeKinugasaandYoshihiroMoriya
rectum resection:::::::::::::::::::::::::::::::::::::::::::::::::: 85
Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 57 PeterMetzger
Fascialstructuresaroundtherectum:::::::::::::::::::::::::::::::::: 57
Fasciapropriaoftherectum::::::::::::::::::::::::::::::::::::::::::: 57 Thecurrenttreatmentofrectalcancerinvolves
Denonvilliers’fascia:::::::::::::::::::::::::::::::::::::::::::::::::::::: 57 amultidisciplinaryapproachinordertoachieve
Pre-hypogastricnervefascia::::::::::::::::::::::::::::::::::::::::::: 58 threeprimarygoals:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 85
Parietalpresacralfascia:::::::::::::::::::::::::::::::::::::::::::::::::: 58 Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 85
Rectosacralfascia:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 59 Laparoscopictechniqueforintersphincteric
Autonomicnerves::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 59 rectalresection:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 86
Superiorhypogastricplexus::::::::::::::::::::::::::::::::::::::::::: 59 Advantages:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 86
Hypogastricnerves:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 59 Disadvantages:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 86
Pelvicsplanchnicnerves:::::::::::::::::::::::::::::::::::::::::::::::: 59 Indications–contraindications::::::::::::::::::::::::::::::::::::::::::: 86
Pelvicplexus::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 60 Technicalrequirements:::::::::::::::::::::::::::::::::::::::::::::::::::::: 87
Levatoraninerves::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 60 Standardizedsurgicaltechniqueofthelaparoscopic
Pudendalnerves::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 60 partofintersphinctericrectumresection::::::::::::::::::::::::::::: 89
Musclesandstructuresaroundtheanalcanal::::::::::::::::::::: 60 Pneumoperitoneumandport-positions:::::::::::::::::::::::::::: 89
Analcanal::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 60 Beginofthelaparoscopicpreparation::::::::::::::::::::::::::::: 89
Levatoranimuscle:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 60 Shouldwealwaysmobilizethesplenicflexure
Rectourethralismuscle::::::::::::::::::::::::::::::::::::::::::::::::::: 61 inthesurgeryofthelowerrectalcancer?::::::::::::::::::::::: 90
Anococcygealligament:::::::::::::::::::::::::::::::::::::::::::::::::: 61 Divisionoftheinferiormesentericvessels:::::::::::::::::::::: 91
Internalanalsphincter:::::::::::::::::::::::::::::::::::::::::::::::::::: 62 LaparoscopicTME:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 91
Externalanalsphincter::::::::::::::::::::::::::::::::::::::::::::::::::: 62 Lateraldissection::::::::::::::::::::::::::::::::::::::::::::::::::::::: 91
Conjointlongitudinalmusclelayeroftheanalcanal::::::: 62 Dorsaldissection:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 92
Anteriordissection::::::::::::::::::::::::::::::::::::::::::::::::::::: 92
Endofthemesorectum:::::::::::::::::::::::::::::::::::::::::::::: 93
The history of rectal resection: The quest
Perinealpart:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 93
for sphincter preservation:::::::::::::::::::::::::::::::::: 65 Clinicalandpathologicaldata:::::::::::::::::::::::::::::::::::: 94
BrigitteKovanyi-Holzer Operationdata,Complications:::::::::::::::::::::::::::::::::::: 95
Functionaloutcome:::::::::::::::::::::::::::::::::::::::::::::::::::: 95
Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 65 Discussion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 95
Perinealapproach:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 65 Windowstothefuture::::::::::::::::::::::::::::::::::::::::::::::::::::::: 96
Sacralapproach::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 65
Theabdominoperinealapproach::::::::::::::::::::::::::::::::::::: 66
Laparoscopic intersphincteric resection
Sphincter-savingsacralresection:::::::::::::::::::::::::::::::::::: 69
for ultra-lowrectal cancer:::::::::::::::::::::::::::::::::: 99
CarloStaudacherandElenaOrsenigo
Surgicaltechnique of intersphincteric
resection:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 73 Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 99
RudolfSchiessel Indications,advantages,anddisadvantagesoflaparoscopic
intersphinctericresection::::::::::::::::::::::::::::::::::::::::::::::: 100
Introduction:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 73 Howislaparoscopicintersphinctericresectiondone?::::: 101
Indications:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 73 Discussion:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 105
Contents ix
Aconcept of sphincter salvage in low Pathologicfindings::::::::::::::::::::::::::::::::::::::::::::::::::::::: 137
rectal cancer:::::::::::::::::::::::::::::::::::::::::::::::::::::: 111 Functionaloutcome:::::::::::::::::::::::::::::::::::::::::::::::::::::: 137
Recurrencesandsurvival:::::::::::::::::::::::::::::::::::::::::::::: 137
EricRullier,QuentinDenost,andChristopheLaurent Conclusion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 138
Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 111
Limitsoftheabdominoperinealresectionprocedure:::::::::: 111 ISR practice and experience for extra-low
Sphincterpreservation:Evolutionoftheconcept rectal cancer in China::::::::::::::::::::::::::::::::::::::: 139
andnewrules::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 112
Bordeaux’surgicalstrategyforlowrectalcancer:::::::::::::: 112 ZhenjunWangandJiagangHan
SurgicaltechniqueofISR::::::::::::::::::::::::::::::::::::::::::::::::: 114
Abdominalstep:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 114 EpidemiologyofrectalcancerinChina:Includingcancer
Perinealstep::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 114 incidence,distribution,etc.::::::::::::::::::::::::::::::::::::::::::::::: 139
PersonalresultsofISR::::::::::::::::::::::::::::::::::::::::::::::::::::: 114 CurrenttreatmentofrectalcancerinChina::::::::::::::::::::::: 139
Oncologicresults:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 115 ISRspecificationsinChina::::::::::::::::::::::::::::::::::::::::::::::: 139
Functionalresults:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 115 TheproposalofmodifiedpartialISR:::::::::::::::::::::::::::::::: 140
Laparoscopicexperience::::::::::::::::::::::::::::::::::::::::::::::::::: 116 ResultsofISRstudy::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 140
Howtomanagedifficultcases?::::::::::::::::::::::::::::::::::::::::: 116 ISRinclusioncriteria:::::::::::::::::::::::::::::::::::::::::::::::::::: 141
Intraoperativedifficulty::::::::::::::::::::::::::::::::::::::::::::::::: 116 ISRdoesnotincreasecomplicationsaftersurgery::::::::: 141
R1resectionafterISR::::::::::::::::::::::::::::::::::::::::::::::::::: 117 ISRdoesnotincreaselocalrecurrencerate:::::::::::::::::::: 141
FaecalincontinenceafterISR:::::::::::::::::::::::::::::::::::::::: 117 ISRdoesnotreducesurvivalrate:::::::::::::::::::::::::::::::::: 142
ISRhasabetterpostoperativeanalfunction:::::::::::::::::: 142
TheadvantagesoflaparoscopicISR:::::::::::::::::::::::::::::: 143
Oncologic and functional outcomes
of external sphincter resection:::::::::::::::::::::::: 121
Intersphincteric resection of low rectal
KazuoShirouzuandYutakaOgata
tumors: Experience from a German
Abstract::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 121 CancerCenter:::::::::::::::::::::::::::::::::::::::::::::::::::: 145
Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 121 JonasG€ohl,WernerHohenberger,andSusanneMerkel
Patientsandmethods:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 121
Patients:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 121 Summary::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 145
Operativetechniques::::::::::::::::::::::::::::::::::::::::::::::::::::: 122 Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 145
Oncologicassessmentandselectionoftheoperative Patientsandmethods:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 145
procedure::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 122 Patients:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 145
Functionalassessment::::::::::::::::::::::::::::::::::::::::::::::::::: 123
Patientselectionforabdomino-peranalintersphincteric
Postoperativefollow-up:::::::::::::::::::::::::::::::::::::::::::::::: 124 resection::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 147
Statisticalanalysis:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 124
Techniqueofabdomino-peranalintersphincteric
Results::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 125 resection::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 147
Preoperativecharacteristicsofthepatientsandtumors::: 125 Results::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 148
Surgicaloutcomes::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 125 Neoadjuvantoradjuvantradiochemotherapy:::::::::::::::::: 148
Pathologicaloutcomes:::::::::::::::::::::::::::::::::::::::::::::::::: 125 Operativeprocedures:::::::::::::::::::::::::::::::::::::::::::::::::::: 148
Oncologicoutcomes::::::::::::::::::::::::::::::::::::::::::::::::::::: 126 Distalmarginofclearance:::::::::::::::::::::::::::::::::::::::::::: 149
Functionaloutcomes::::::::::::::::::::::::::::::::::::::::::::::::::::: 126 Circumferentialmargin::::::::::::::::::::::::::::::::::::::::::::::::: 149
Discussion:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 127 R0resections:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 150
Stagedistribution:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 150
Postoperativecomplicationsandmortalityrates::::::::::::: 150
Intersphincteric resection for very low rectal Locoregionalrecurrences:::::::::::::::::::::::::::::::::::::::::::::::::: 150
cancer.Special reference to surgical Cancer-relatedsurvivalrates::::::::::::::::::::::::::::::::::::::::: 151
techniques::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 131 Conclusion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 151
YoshihiroMoriya
Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 131 Transanal abdominal transanal
Anatomyoftheanalcanal:::::::::::::::::::::::::::::::::::::::::::::::: 131 proctosigmoidectomy with descending
Patientselection::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 132 coloanalanastomosis (the TATA procedure)
Surgicaltechniques::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 132
for low rectal cancer treatedwith
Abdominalapproaches:::::::::::::::::::::::::::::::::::::::::::::::::: 132
Pelvicapproaches::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 133 chemoradiation::::::::::::::::::::::::::::::::::::::::::::::::: 153
Firststepofthepelvicdissection:::::::::::::::::::::::::::::::::: 133 JohnH.Marks,GeorgeJ.Nassif,andGeraldMarks
Secondstepofpelvicdissection:::::::::::::::::::::::::::::::::::: 134
Thirdstepofpelvicdissection::::::::::::::::::::::::::::::::::::::: 134 Technicaldescription:::::::::::::::::::::::::::::::::::::::::::::::::::::::: 154
Trans-analapproach:::::::::::::::::::::::::::::::::::::::::::::::::::::: 135 Abdominalportionofoperation:::::::::::::::::::::::::::::::::::::::: 156
Patientposition::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 135 Abdominalportion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 156
Coloanalanastomosis:::::::::::::::::::::::::::::::::::::::::::::::: 136 Pelvicportion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 156
Pathological,functionalandoncologicaloutcomes:::::::::::: 137 Overallresults:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 157
Morbidity::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 137 Conclusion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 158
x Contents
Robot-assisted intersphincteric resection:::::::: 159 Do we need apouch afterintersphincteric
SeonHahnKimandJaeWonShin resection?::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 173
RudolfSchiessel
Operationroomsetup,patientpositioning,andport
placement::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 159 Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 173
Thesurgicalprocedure::::::::::::::::::::::::::::::::::::::::::::::::::::: 160
Management of limitations for sphincter
preservationand functional failure following
Postoperative function
intersphincteric resection::::::::::::::::::::::::::::::::: 177
Quality of life following rectal resection::::::::: 167 HaraldR.Rosen
BrigitteKovanyi-Holzer Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 177
Oncologicallimitations::::::::::::::::::::::::::::::::::::::::::::::::::::: 177
Introduction::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 167 Functionalfailurefollowingintersphinctericresection::::::: 179
Socialwell-being:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 167
Psychologicalwell-being:::::::::::::::::::::::::::::::::::::::::::::::::: 167
Preoperativeexpectations:::::::::::::::::::::::::::::::::::::::::::::: 168 List ofcontributors:::::::::::::::::::::::::::::::::::::::::::::: 183
QOLinstruments:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 169
Socialfactors(education,religion):::::::::::::::::::::::::::::::: 170 Subjectindex:::::::::::::::::::::::::::::::::::::::::::::::::::::: 185
Conclusion::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 171 About the editors:::::::::::::::::::::::::::::::::::::::::::::::: 189
Pathology of low rectal cancer
The pathological assessment of the
surgical specimens originating from
the lower rectum and anal canal
Barna Bogner
Development and anatomy of the levator muscle [3–5]. The wall of the anal canal is
anorectal wall and surrounding composed of the anal canal mucosa, submucosa, and
structures muscularis,whichiscomposedofthethickinnercircular
layer,servingastheinternalsphincterwhereastheouter
The most profound investigation of the anorectal devel- longitudinallayercontinueswithasmalllayerofconnec-
opmentwasperformedbyAigneretal.on79fetusesfrom tivetissuewhichseparatesthelongitudinallayerfromthe
the ninth week on postconceptionem [1]. According to striated external sphincter. The inner circular layer is a
their results during the early prenatal life, the muscular continuationofthecircularmusclecoatoftherectumbut
layersoftherectumandoftheanalcanalderivefromthe is considerably thicker. Its thickness varies depending
mesenchymethataccompaniestheendodermalpartofthe upon the height, the mode of investigation and among
anorectum. The inner circular layer of the rectum pre- investigators – according to Sternberg, in histological
cedestheouterlongitudinallayerduringtheseventhweek sections it measures 5 to 8mm and ends 5 to 19mm
of embryonic development. The anlagen of the levator belowthedentateline[3],whereasitisonly1.5to3.5mm
muscle and the external sphincter occur within the sur- thickaccordingtotheGray’sAnatomy.Theopinionsvary
roundingmesenchymae.Theyareclearlyseparatedfrom on the anatomy of the longitudinal muscle as well.
each other and they both show the signs of proliferative According to Shafik it consits of three layers, whereas
activitywhentheygetincontactwiththebundlesofthe othersregarditasaconjointcoat[3,4].Atthelowerendof
smoothmusclesderivingfromtheouterlongitudinallayer theinternalsphincteritbreaksupintoanumberofseptae,
oftherectalwall.Asaresultboththelevatoraniandthe which divergefanwisethroughthesubcutaneouspartof
externalsphinctergrowlargerandgetincontact(Fig.1). the external sphincter. There is no complete agreement
The levator ani muscle is continuous with the deep eitheroverthenumberofmusclefibersofthelowerpartof
portionoftheexternalanalsphinctermuscle.Atthelevel longitudinal muscle, oroverits composition.According
withthepuborectalisportionofthelevatoranimuscle,the toMorganandThompson,thefibersbecomemorefibro-
rectaladventitiaconstitutesathin,microscopiclayerthat elastic [5] or completely fibro-elastic [4] as they pass
is interposed between the outer longitudinal muscular throughtheexternalsphincter.Macchietal.investigated8
layer and the inner fascia of the levator ani muscle. maleand8femalecadavers(agerange52–72years)with
This is an important finding as there is a contradiction specialstainsforelasticfibersandusingmonoclonalanti-
oftheintepretationofthisregionintheanatomicaltext- human alpha-smooth muscle actin and monoclonal
books which has an effect on staging and therapeutical anti-rabbit sarcomeric actin and monoclonal anti-rabbit
procedures.TheschematicdrawingintheAJCCCancer sacromeric actin.Althoughtheyagreethatthe proximal
Staging Atlas depicts a situation where the levator ani attachment of the longitudinal anal muscle (LAM) is in
muscleisattachedtothemuscularlayeroftherectumover continuity with the longitudinal muscle of the rectum,
theexternalsphincter[2].Asaresulttheinvasionofthe immunohistochemically the muscle showed predomi-
externalsphincterisclassifiedasaT3tumor,whereasthe nantly striated muscle fibers, with a few smooth muscle
involvement of the levator muscle means T4, which is fibers.Oncoronalsectionstheywereabletoidentifythe
contradictoryasbothmuscularstructuresareprimarilyof LAM only in 83% of their specimens, where the LAM
mesodermalorigin[1].Alltheotheranatomicalsources received fibers from the puborectalis muscle and termi-
showadifferentsituation,wherethepuborectalispartof nated in 7–9 fibro-elastic septa which penetrated the
the levator ani muscle is continuous with the external externalanalsphincter[6].Thehistologicalcomposition