Rectal endometriosis: results of radical excision and review of published work

BACKGROUND: The aim of this paper is to review the results of surgical excision of rectal endometriosis and review the published work on this challenging condition. METHODS: All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed. RESULTS: Between 1995 and 2005, 213 rectal procedures were carried out on 203 patients together with an endogynaecologist. Eighteen cases involved dissection of endometriosis off the rectal wall, 58 involved full-thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were carried out. A loop ileostomy was required in 7 (5%) of the segmental resections. Seventy-five per cent of the cases were either laparoscopic or laparoscopically assisted. Infertility was significantly more common in the group requiring a segmental resection (P=0.026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P=0.031). There were no other significant differences between the different types of rectal surgery. The morbidity for all rectal procedures was 7% and there was one anastomotic leak in the segmental resection group. The actuarial rectal recurrence rate of endometriosis was 22.2% 95% confidence interval (CI) (2.5, 42.0) for dissection off the rectal wall and this was significantly different from the recurrence of 5.17% 95%CI (0.0, 10.9) for anterior rectal wall excision and 2.19% 95%CI (0.0, 4.6) for segmental rectal resection (P=0.007). The overall rectal recurrence for all cases was 4.69% 95%CI (1.8, 7.5). CONCLUSION: Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.     

Trans-suture mechanical colorectal anastomosis using a double stapler in the anterior resection of the rectum. Technical note

The spread of mechanical staplers now makes it possible to perform anastomoses in anterior resections of the rectum that are easier and safer than manual ones. Certain related problems are well known, particularly in patients with narrow pelvis and, in low anastomoses, the fashioning of the tobacco pouch on the distal rectal stump. The technique of transutural mechanical colorectal anastomosis with circular stapler after closure of the rectal stump with linear stapler is described in detail. Advantages of the technique are: anastomoses that are technically easier and safer because making of the tobacco pouch on the distal rectal stump is avoided; pollution of the operating field is reduced to the minimum; there are no problems related to differences in lumen of the colorectal stumps.     

Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line

BACKGROUND: Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required. STUDY DESIGN: Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally. RESULTS: The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management. CONCLUSIONS: In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.     

Use of vascular endostapler in surgery of the lower rectum

A practical and effective method for rapid and bloodless preparation of the rectum using endovascular stapler devices during low anterior resection, or abdominal-perineal excision, is described. This method is presented as an effective means for easily dividing the anterior and lateral attachment of the rectum. The application of this technique is the absence of intraoperative bleeding related to injury of middle hemorrhoidal vessels, with minimal risk of autonomic pelvic nerve damage. An additional factor relevant in the choice of this technique, is the easier possibility to perform rectal dissection of an oncologically adequate tumor clearance from the margin of rectal tumor and with complete radical transection of the lateral ligaments fastly proceeding with the downward mobilization of the rectum close to the pelvic side walls, between the parietal and visceral layer of the pelvic fascia.     

Low anterior resection of the rectum using a double stapling technique

Using a double stapling technique in 30 patients, anterior resection of the rectum was attempted for low rectal carcinoma (n = 28), giant rectal adenoma (n = 1) and radiation-induced rectal stricture (n = 1). There were three emergency operations. The rectum was stapled transversely more than 3 cm below the tumour using the adjustable-angle linear stapler (Roticulator). Colorectal or coloanal anastomoses were constructed using the EEA circular stapler introduced per anum through the anorectal stump staple line. Ten coloanal and 19 low rectal anastomoses were achieved. A protecting transverse loop colostomy was fashioned in one patient with coloanal anastomosis who developed a vaginal tear during the procedure. In one patient technical failure necessitated conversion to abdominoperineal excision of the rectum. All staple rings and resection margins were intact and free from tumour. There were two clinical anastomotic leaks, both treated successfully with a defunctioning transverse loop colostomy. One patient developed a small infective pelvic haematoma 2 weeks after surgery which required drainage. Hospital stay ranged from 6 to 15 days (mean 8 days). Continence was normal in all patients at 8 weeks. One soft coloanal anastomotic stricture required dilatation. No recurrences have been detected during a follow-up of between 10 and 22 months.     

Laparoscopic repair of full-thickness bowel injury.

Laparoscopic resection of full-thickness lesions of the anterior rectum followed by repair using a two-layer suture technique is described. Anterior rectal laceration occurred in two bowel-prepped women during excision of deep fibrotic endometriosis. Neither patient required subsequent surgery nor suffered any postoperative sequela. While not all rectal injuries are suitable for laparoscopic suture repair, in selected cases, bowel injury can be effectively managed laparoscopically without resorting to major abdominal surgery.     

The circular stapling device as a risk factor for anastomotic leakage

AIM: To investigate the relation between the type of circular stapler and anastomotic leak in rectal cancer surgery. BACKGROUND: During the past decades results from rectal cancer surgery have improved considerably regarding risk of local recurrence and survival. Two main paradigm changes are considered to be the cause for this: the introduction of total mesorectal excision (TME) and the increasing use of radiotherapy. However, rectal cancer surgery is associated with an unacceptably high frequency of complications of which anastomotic leak is one of the most severe ones. The hypothesis was raised that the choice of stapler influenced the leakage rates. METHODS: A questionnaire was sent to all departments of surgery (n = 66) performing rectal cancer surgery in Sweden to determine the choice of circular stapler when performing anterior resection for rectal cancer. These data were linked to the Swedish Rectal Cancer Registry for the period 1995-99. RESULTS: A total of 3316 patients had an anterior resection. The choice of circular stapling device was determined in 70% of the cases. When stapler A was used, the leakage rate was 11% whereas it was 7% when stapler B was used (P = 0.0039). In the cases where it was impossible to determine which stapler had been used the leakage rate was 8%. CONCLUSION: Quality control is an important part of medicine and the present study suggests that it also must include surgical instruments. A prospective randomised study is needed to confirm the results.     

Completely Laparoscopic Total Colectomy for Chronic Constipation: Report of a Case

Laparoscopic surgery has had a remarkable impact on the practice of colorectal surgery. However, most operations are performed using a technique of laparoscopic assistance, whereby extracorporeal bowel division and anastomosis are made following laparoscopic mobilization of the bowel. To our knowledge, this is the first report to describe a case of chronic constipation managed by total colectomy with ileorectal anastomosis, performed completely laparoscopically. The diagnosis of slow transit constipation was made by a transit time study. After dissection of the entire colon, the colon to be resected was delivered through the open rectal stump and brought out transanally. The anvil of an intraluminal circular stapler was passed through the rectum into the peritoneal cavity and the end of the open distal rectum was closed with a linear cutting stapler. The anvil of the circular stapler was inserted into the end of the open terminal ileum and fixed with an Endo-Loop, following which an intracorporeal double-stapling anastomosis was performed. By 3 months following surgery, the patient was passing 3–4 stools a day. Thus, we highly recommend this technique as it eliminates the need for a small incision to deliver the resected colon, thereby minimizing the operative time and risk of wound infection. Received: August 23, 2001 / Accepted: January 8, 2002     

Simple repair of complex rectovaginal fistulas.

We describe a successful anterior rectal wall advancement flap in two patients with complex rectovaginal fistulas. Our technique used a wide transversely-incised flap, which ensures adequate blood supply, facilitates wide dissection, allows approximation of the anterior rectal wall without tension, and secures closure of the orifice of the fistula.     

Anatomy of Denonvilliers' fascia and pelvic nerves, impotence, and implications for the colorectal surgeon

BACKGROUND: The development and anatomy of Denonvilliers' fascia have been controversial for many years and confusion exists about its operative appearance. Better appreciation of this poorly understood anatomy, and its significance for impotence after rectal dissection, may lead to further functional improvements in pelvic surgery. METHOD: A literature review of the embryology and anatomy of Denonvilliers' fascia and impotence after pelvic rectal surgery was undertaken. RESULTS: Denonvilliers' fascia has no macroscopically discernible layers. The so-called posterior layer refers to the fascia propria of the rectum. The incidence of erectile and ejaculatory dysfunction after rectal excision is high in older patients, and when performed for rectal cancer. There is no consensus about the relationship of Denonvilliers' fascia to the plane of anterior dissection for rectal cancer. CONCLUSION: Colorectal surgeons should focus on the important anatomy between the rectum and the prostate to improve functional outcomes after rectal excision. A classification of the available anterior dissection planes is proposed. Surgeons should be encouraged to document the plane used as well as outcome in terms of sexual function.     

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection

Background Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed. Methods The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon. Results Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%). Conclusions Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).     

A technique for safe transanal passage of the circular end-to-end stapler for low anterior anastomosis of the colon

Two techniques are currently available for the creation of low anterior rectal stapled anastomoses. The first technique requires the placement of a pursestring suture at the superior margin of the rectal cuff, which is technically difficult. In the second technique, the rectal cuff is closed with a linear stapler. The circular end-to-end stapler, with the anvil removed, is then passed through an enterotomy in the rectal remnant. We describe an easy and safe method that obviates difficulties during the transanal passage of the stapler and minimizes the risk of injury to the rectum. This method uses an inexpensive and readily available rubber catheter and metal guide.     

弧形切割吻合器在低位直肠癌超低位前切除术中的应用

目的总结弧形切割吻合器在低位直肠癌超低位前切除术中的应用价值。方法2005年12月至2006年9月选择56例低位直肠癌患者在全直肠系膜切除和侧方淋巴结清扫的基础上,应用弧形切割吻合器对直肠(肛管)残端进行切割、闭合,用33mm管型吻合器进行超低位结肠-直肠(肛管)吻合术。结果56例低位直肠癌患者术中没有发生切割和闭合不全的病例,吻合口无渗漏。手术后住院时间为(11.2±3.2)d,无死亡者。发生吻合口瘘2例(3.6%),经过局部引流而自然愈合1例,因直肠阴道瘘进行横结肠造口转流1例,无吻合口狭窄。结论弧形切割吻合器在低位直肠癌超低位前切除术中具有切割完整、闭合确实、吻合口瘘发生率低的优点,有良好的应用推广价值。     

MANAGEMENT OF THE RECTUM FOLLOWING COLECTOMY FOR ACUTE COLITIS

During a 6 year period, 31 consecutive patients under the care of one surgeon had emergency colectomies for complicated colitis. A selective policy of closing the rectum intraperitoneally to minimize the length of retained diseased bowel and to avoid a mucus fistula was used during the study period. One patient underwent proctocolectomy, 7 subtotal colectomy with mucus fistula and 23 total colectomies with intraperitoneal closure of the rectum. Two patients (8.9%) developed pelvic sepsis. Both had intraperitoneal closure of the rectal stump and were readily managed by drainage into the stump. Subsequent surgery in the 18 patients having rectal excision has been uncomplicated. Intraperitoneal closure of the rectal stump in emergency surgery for complicated colitis can be performed safely in most of these patients.     

Rectal carcinoma. Optimizing therapy by partial or total mesorectum removal]

The role of total mesorectal excision for rectal cancer treatment is one of the most exciting findings in surgical oncology of the recent years. The patient's prognosis largely depends on the surgical quality of rectal resection. The excision of the cancer bearing rectum has to follow very precisely along the mesorectal fascia by sharp dissection without damaging the mesorectum itself. This technique reduces the local recurrence rate to below 10% and allows long-term survival in two thirds of all patients. Rectal cancers of the middle and lower third of the rectum need to be treated by total mesorectal excision down to the muscular pelvic floor, the ones of the upper third and the sigmoideo-rectal junction are appropriately treated by partial mesorectal excision down to 5 cm below the tumor. No additional survival benefit may be expected when pelvic lymphadenectomy has been performed. The direct tumor spread along the bowel wall and the lymphatic tumor spread in a caudal direction are uncommon and late findings in rectal cancer disease. Low and ultralow rectal carcinomas may therefore be treated by a sphincter preserving procedure respecting a safety margin of at least 1 to 2 cm. Thus, continence preserving surgery may be performed in over 80% of patients suffering from rectal cancer without compromising long-term outcome.     

Management of the rectum following colectomy for acute colitis.

During a 6 year period, 31 consecutive patients under the care of one surgeon had emergency colectomies for complicated colitis. A selective policy of closing the rectum intraperitoneally to minimize the length of retained diseased bowel and to avoid a mucus fistula was used during the study period. One patient underwent proctocolectomy, 7 subtotal colectomy with mucus fistula and 23 total colectomies with intraperitoneal closure of the rectum. Two patients (8.9%) developed pelvic sepsis. Both had intraperitoneal closure of the rectal stump and were readily managed by drainage into the stump. Subsequent surgery in the 18 patients having rectal excision has been uncomplicated. Intraperitoneal closure of the rectal stump in emergency surgery for complicated colitis can be performed safely in most of these patients.     

腹腔镜直肠癌根治术(Dixon)

在结肠系膜与后腹膜移行处切开后腹膜,分离系膜至肠系膜下动脉根部,清扫253组淋巴结,在距腹主动脉根部1 cm处夹闭并切断血管,切断肠系膜下静脉。由内侧向外侧分离结肠系膜至结肠旁沟,切开其左侧后腹膜,将降结肠及乙状结肠系膜从后腹壁游离。沿直肠固有筋膜与盆壁筋膜的间隙按照TME原则锐性分离直肠系膜,先游离后壁,再游离两侧壁及前壁,直至盆底。在肿瘤下方2 cm处用阻断夹夹闭肠管,冲洗远端直肠,用切割缝合器切断直肠。取脐部弧形切口。提出近端肠管,于肿瘤近端15 cm处离断肠管。近端置入管型吻合器抵钉座,还纳腹腔,重建气腹。经肛置入管型吻合器,在腹腔镜直视下作乙状结肠－直肠端端吻合,冲洗腹腔,置引流管,手术结束。     

INITIAL CLINICAL EXPERIENCE WITH THE EEA STAPLER

In the initial clinical experience using the EEA stapler in twenty patients there were no instances of anastomotic leakage in five patients undergoing sigmoid colectomy and partial upper rectal excision or high anterior resection of the rectum. There were five Instances of confirmed anastomotic leakage (radiological or autopsy) of fifteen patients undergoing low anterior resection of the rectum. Benign anastomotic stenosis developed In three patients. The technique of anastomosis after low anterior resection remains a challenge and there is no justification lor less stringent training in hand sewn anastomoses because of the introduction of the EEA stapler.     

TaTME approach as a rescue during a laparoscopic TME for high rectal cancer. A case report

Introduction and importanceIn the last years, transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients, difficulties in pelvic exposure and limitations of instrumentation improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure.Here we report a case report of anterior laparoscopic rectal resection for adenocarcinoma of the high-mid rectum converted to transanal approach.Case presentationA 69-year-old male presented hepatic nodules during radiological follow-up for prostate cancer treated with radical prostatectomy and adjuvant radiotherapy (70 Gy). The biopsy of the lesion demonstrated the presence of a metastatic lesion of an adenocarcinoma, with suspected intestinal origin. Then, we perform an endoscopic examination, which showed the presence of a rectal lesion, which cause a bowel stenosis extended from the middle part to the upper part of the rectum.After chemoradiotherapy, an anterior rectal resection was performed. During surgery we could not perform the resection of the rectum due the thickness and fibrosis of the tissue, despite we used different branded mechanical stapler. So, we decided to complete the surgical treatment starting a TaTME procedure with resolution of the problem.Clinical discussionTaTME is a relatively new technique that had already become a valid option in the treatment of low rectal cancer, and, nowadays, also in the treatment of inflammatory bowel disease. As reported in literature, this technique has a number of advantages, especially in narrow pelvis and it is very useful in low rectal surgery.ConclusionThis case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice.     

Anterior resection of the rectum--a simplified stapling technique.

The use of a double stapling technique in anterior resection of the rectum eliminates the necessity for a rectal stump pursestring and removes the problem of tissue pouting on the spindle of the circular EEA stapler when a voluminous rectum is pulled onto it with the pursestring. We have used this technique in 20 patients with tumours in the middle and lower thirds of the rectum without complication. This technique may reduce contamination in the pelvis and certainly shortens operating time. Cost effectiveness of the technique should be evaluated in busy centres where the benefit would appear to be greatest.