Rectal cancer: diagnosis, screening and treatment

Rectal cancer is one of the primary malignant neoplasms occurring in Mexican patients of reproductive age. Unfortunately, randomized studies in rectal cancer do not exist as they do with well-recognized colon cancer. We must individualize the epidemiology, risk factors, diagnostic approach, staging and treatment because management is different in rectal cancers affecting the mid- and lower third of the rectum than in the upper third and in colon cancers. Histological staging is the primary prognostic factor. TNM staging (tumor, node, and metastasis) is used internationally by the American Joint Committee on Cancer (AJCC). Staging is done with the assistance of endorectal ultrasound, which is best used in early-stage cancer; however, there are certain disadvantages in detecting node involvement. Magnetic resonance, on the other hand, allows for the evaluation of stenotic tumors and node involvement. Once the correct diagnosis and staging have been made, the next step is correct treatment. Neoadjuvant treatment has demonstrated to be better than adjuvant treatment. Abdominoperineal resection is rarely practiced currently, with sphincter preservation being the preferred procedure. Laparoscopic approach has conferred the advantages of the approach itself when performed by experts in the procedure but there is insufficient evidence to make it the "gold standard." Rectal cancer is a complex pathology that must be considered totally different from colon cancer for diagnosis and treatment. The patient must be staged completely and appropriately for individualizing correct treatment. More long-term studies are needed for optimizing treatment modalities.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Treatment of hemorrhoids: report of a technique

A technique for the treatment of hemorrhoids has been presented. It is based on a recent study in which the persistence of the anorectal band, a remnant of the anorectal sinus, and failure of rectal neck remodeling are considered responsible for the initiation of the hemorrhoid disease. The constricting effect of the anorectal band on the rectal neck results in elevation of its pressure, straining at defecation, and prolapse of the rectal mucosa. There were 502 patients with third and fourth degree hemorrhoids. The preoperative rectal neck pressure was high in all of them. The technique comprises division of the anorectal band and hemorrhoid ligation. The results were satisfactory, and the complications were negligible. The rectal neck pressure was normalized and straining disappeared. The procedure is simple and easy. Compared with the other techniques for hemorrhoid treatment, it offers the advantage of dealing with the primary etiologic factor.     

Résection transanale des tumeurs villeuses du rectum

The local resection of rectal villous tumours is most often indicated for tumours located in the lower third of the rectum. It allows resection of large tumours. The use of a rectal mucosa tractable flap procedure assists the resection of higher-level tumours. During this procedure, it is easy to view the macroscopic boundaries of the tumour as well as the deep dissection field. It is crucial to obtain a complete and whole specimen for histological evaluation. The limits of this technique are malignant tumours. Indication of a complementary treatment depends on the level of infiltration and histological characteristics of the malignant component.     

Posterior surgical approaches to the rectum.

This report summarizes experience with 19 posterior approaches to the rectum including nine trans-sacral (Kraske) and ten trans-sphincteric (Mason) procedures. This study included 12 men and 7 women, ranging in age from 18 to 89 years. Surgical indications included villous tumors in nine patients, various benign problems in four patients, primary carcinomas in three patients, and recurrent cancer in three patients. Eight complications developed in the 19 patients including: four fecal fistulae, two wound dehiscences, one rectal stricture, and one sacrococcygeal hernia. Spontaneous closure of the fecal fistulae occurred in two patients, and two patients required proximal colostomies. Fecal continence was achieved in 18 of the 19 patients. No patient died as a complication of the procedure. No recurrent tumors have developed. The conclusion is that a posterior approach to the rectum is a safe and effective procedure for various benign and for selected malignant conditions. It is particularly suitable for villous tumors that are too high for transanal resection and too low for transabdominal resection. It is an effective procedure for small, exophytic, mobile carcinomas of the lower 10 cm of the rectum in selected patients.     

Treatment of tumors of the third ventricle: a new and simple technique.

A new surgical technique is described for the treatment of benign cystic tumors of the third ventricle. It basically consist of: 1) introduction of a catheter to the third ventricle, therefore to the cyst; 2) suction of all the material of the cyst; 3) connection of the catheter to a ventriculoatrial shunt. A report of five patients with a possible colloid cyst in the third ventricle treated with this technique and the satisfactory results obtained in all the cases, with lack of morbidity and mortality, is presented. A comparison between the traditional surgical procedure and ours, as far as the technique itself and the results are concerned, is made. The simplicity of the technique is emphasized and it is proposed as another solution for the treatment of cystic tumors of the third ventricle.     

Transanal endoscopic microsurgery (TEM)

Minimally invasive surgery is mandatory for rectal tumors to reduce surgical complications and to improve the quality of life. The conventional transanal procedure is one from of minimally invasive surgery for rectal tumors, but it is still often difficult to reach the middle and upper thirds of the rectum due to anatomical characteristics. Transanal endoscopic microsurgery (TEM) is a technique that allows radical resection of rectal tumors in the distal as well as proximal third of the rectum. Performing radical surgery using this technique requires preoperative estimation of tumor extension both histologically and by X-ray images. It should allow provide safe and radical excision of rectal tumors. In our department, patients with rectal tumors are evaluated for risk factors using barium enema, endoscopic ultrasound, punch biopsy, etc. Fifty patients (rectal cancer, 34: cartinoid, 4: adenoma, 12) have undergone radical TEM. The operation was converted to open surgery in 2 cases because of rectal perforation. Radical open surgery was performed after TEM in 1 patient since cancer invasion was revealed by postoperatively upon histological examination. We conclude that TEM is a useful technique for radical resection of rectal tumors and is associated with a low rate of postoperative complications and a high surgical success rate.     

Transanal endoscopic microsurgery for rectal tumors: the St. Mary's experience

BACKGROUND: The aim of this study is to describe a single institution's experience in the use of transanal endoscopic microsurgery for rectal tumors. METHODS: Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients. RESULTS: Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively. COMMENTS: Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions.     

Anterior callosal section is useful for the removal of large tumors invading the dorsal part of the anterior third ventricle: operative technique and results

Large tumors invading the dorsal part of the anterior third ventricle are difficult to manage. The anterior transcallosal approach is usually used to manage these tumors. In our clinic, anterior callosal section was combined with the anterior interhemispheric (AIH) translamina terminalis approach for these tumors with excellent results. The AIH approach is useful for removing tumors in and around the anterior part of the third ventricle. However, AIH alone is insufficient for large tumors invading the dorsal part of the anterior third ventricle. In such situations, simple anterior callosal section enables the neurosurgeon to extirpate the caudal part of the tumors deeply hidden from operative field, sparing the foramen of Monro, fornix, etc. We treated four large tumors (malignant teratoma, recurrent chordoid glioma, recurrent papillary tumor of pineal region occupying the third ventricle, and paraventricular meningioma) without major complications. The malignant teratoma case exhibited no recurrence with >10 years follow-up. The chordoid glioma and papillary tumor of pineal region were totally removed. The meningioma was subtotally removed except only a small tumor around the bilateral anterior cerebral artery. This simple technique is a new way to manage difficult large lesions in and around the third ventricle.     

弧形切割吻合器在超低位直肠癌保肛手术中的应用

目的 探讨应用弧形切割吻合器在超低位直肠癌保肛手术中应用的可行性.方法 2006年1-10月,对36例超低位直肠癌患者采用弧形切割吻合器(ContourTM),在全直肠系膜切除的基础上完成保肛手术.结果 患者均成功完成了手术.术后病理证实,切缘均无肿瘤残留;无吻合口瘘、吻合口狭窄、局部复发.结论 应用弧形切割吻合器行超低位直肠癌保肛手术,使双吻合器技术更加方便,扩大了超低位直肠癌保肛手术的适应证范围.     

低位直肠癌保肛术后吻合口漏的原因及防治现状

目的分析低位直肠癌保肛术后吻合口漏的常见原因,以探索更好的预防及治疗策略。方法采用文献复习的方法对吻合口漏的定义、常见原因、防治现状等相关文献进行综述。结果目前直肠癌是我国常见恶性肿瘤之一,其中低位直肠癌约占2／3。低位直肠癌保肛手术已成为首选的术式,但保肛术后吻合口漏仍是最严重和常见的并发症之一。通过改善患者一般状况,提高手术技巧,规范化治疗等可有效减少吻合口漏的发生。结论术前合理评估患者基本状况,规范化并个体化治疗,有助于降低吻合口漏的发生率以及改善患者临床结局。     

Intrarectal sonography. A new technique for the assessment of rectal tumors

Preoperative staging of rectal tumors provides a selective therapeutic approach. Twenty-three patients were evaluated with prospective intrarectal sonography. Endosonography identified all 21 rectal lesions. Two patients with previous rectal carcinoma had no evidence of recurrence. Thirteen of 17 patients (76%) with rectal carcinoma were correctly staged by endosonography. A submucosal leiomyosarcoma and pararectal arachnoid cyst were correctly identified. Preoperative assessment of lymph node status was accurate in five of ten patients (50%). Results of preoperative digital rectal examination predicting rectal wall involvement correlated with pathologic findings in 11 of 15 patients (73%). Intrarectal sonography is an important staging technique for preoperative evaluation of rectal wall invasion and guides appropriate surgical intervention.     

低位直肠癌保肛手术中吻合器的应用

目的探讨吻合器在低位直肠癌保肛手术中的应用效果。方法回顾性分析2004年11月至2009年8月256例直肠癌应用全直肠系膜切除联合吻合器行低位直肠前切除的临床资料。结果本组无死亡病例,无生殖功能障碍;发生吻合口漏2例,出现排尿功能障碍6例。结论全直肠系膜切除联合吻合器的应用可保持盆腔脏器功能,是治疗低位直肠癌的有效方法。     

A new technique to achieve sufficient mesorectal excision in upper rectal cancer

BACKGROUND: Appropriate partial mesorectal excision (PME) is extremely important for prevention of local recurrence even in upper rectal cancer. However, it is not always easy to conduct PME in the narrow pelvic cavity. We devised a new surgical technique that involves a rectal transection followed by PME. METHODS: After rectal mobilization in the layer targeted for total mesorectal excision, only the rectal wall was bluntly dissected at an appropriate distance from the tumor. Initial transection of the rectum allows drawing the rectum toward the anal side so that the mesorectum can be confirmed with a good visual field. Excision of the mesorectum was easy, and it could be resected in a short time. RESULTS: This technique was conducted on seven patients with upper rectal cancer and on four patients with rectosigmoid cancer. Separation of the rectal wall was comparatively easy, and we had no incidence of wall injury. The average distance from the rectal stump to the distal mesorectum in the freshly resected specimen was 15 mm, indicating satisfactory PME. CONCLUSIONS:This easily performed method is a promising procedure for achieving sufficient PME in upper rectal cancer.     

Modified anoabdominal rectal resection and colonic J-pouch anal anastomosis for lower rectal carcinoma: preliminary report.

BACKGROUND. There has recently been increasing interest in coloanal reconstruction after proctectomy for low rectal carcinoma. We describe here our pilot experience with seven patients undergoing modified anoabdominal resection of the rectum and a colonic J-pouch anal anastomosis. METHODS. The procedure varied according to the extent of internal anal sphincter (IAS) resection (type a, partial resection of the upper IAS; type b, circumferential resection of the upper IAS; type c, partial preservation of the lower IAS; and type d, total resection of the IAS). RESULTS. None of the patients had incontinence, but preservation of the lower half of the IAS (types a and b) showed functional superiority over more extensive IAS resection (types c and d). Only patients who underwent types c and d resection needed medications to reduce stool frequency. CONCLUSIONS. Our results suggest that the lower half of the IAS has a more important role than the upper half in the control of defecation. Total resection of the IAS did not sacrifice continence, but preservation of at least the lower IAS resulted in a better quality of life. Careful patient selection is needed when considering the use of these procedures for tumors in the lowest part of the rectum.     

Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy

Aim To date fistulotomy is still the treatment of choice for patients with a transsphincteric fistula passing through the lower third of the external anal sphincter, because it is a simple, effective and safe procedure with a minimal risk of incontinence. However, data suggest that the risk of impaired continence following division of the lower third of the external anal sphincter is not insignificant, especially in female patients with an anterior fistula and patients with diminished anal sphincter function. It has been shown that ligation of the intersphincteric fistula tract (LIFT) is a promising sphincter‐preserving technique. Therefore, we questioned whether LIFT could replace fistulotomy in patients with a low transsphincteric fistula. Method A consecutive series of 22 patients with a low transsphincteric fistula of cryptoglandular origin underwent LIFT. Continence scores were determined using the Rockwood Fecal Incontinence Severity Index. Results Median follow‐up was 19.5 months. Primary healing was observed in 18 (82%) patients. In the four patients without primary healing, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulotomy with preservation of the external anal sphincter. The overall healing rate was 100%. Six months after surgery, the median incontinence score was not changed significantly. Conclusion Low transsphincteric fistulae can be treated successfully by LIFT, without affecting faecal continence. Division of the lower part of the external anal sphincter is no longer necessary in the treatment of low transsphincteric fistulae, which is essential for patients with compromised anal sphincters.     

经肛门入路腔镜下高位直肠类癌局部切除术(附6例临床报告)

目的探讨微创保肛切除高位直肠类癌的方法及效果. 方法 2002年8月～2005年1月,我院用自行设计制造的直肠肛门镜与腹腔镜器械配合应用,经肛门切除距肛缘9～12 cm的直肠类癌6例,均为癌周局部切除,切缘距肿瘤0.5～1.0 cm. 结果 6例手术全部成功.术后住院时间3～6 d,术后未应用镇痛药物.随访3～28个月,平均15个月,无复发或转移,无直肠狭窄,无手术引起的近远期并发症. 结论经肛门腹腔镜下高位直肠类癌局部切除术安全,可靠,创伤小,恢复快,治疗费用低廉.     

Leiomyoma of the rectum. A diagnostic and therapeutic dilemma

A case is reported of leiomyoma of rectum, a rare tumor since it is detected in 2 of 3000 rectal tumors. It occurs principally in patients between 40 and 50 years. The tumor is submucosal, is difficult to diagnose and biopsy is often valueless since it does not involve the tumor mass. The interest of the present case is that trans-rectal ultrasound imaging of the leiomyoma was performed. Differential histologic diagnosis between benign and malignant forms is a dilemma, these tumors being of slow growth with a marked tendency for recurrence and malignant degeneration. Treatment should always be surgical, with local resection if histology has excluded malignancy, followed by periodic surveillance. Radical surgery is indicated in malignant forms or for local recurrence of benign tumors.     

Cirugía endoscópica transanal en tumores rectales

Background

Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity.

Methods

In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…).

Results

The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery.All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients.

Conclusions

TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.     

Ultrasonic fragmentation. A new technique for mucosal proctectomy

We report a new technique for mucosal proctectomy that does not require manual separation of the mucosa and submucosa from the underlying muscularis. Mucosal proctectomy using ultrasonic fragmentation of the rectal mucosa was performed in four patients. Three had severe ulcerative colitis, and one patient had radiation proctitis with a rectal stricture. In all cases an endorectal pullthrough with anastomosis to the area of the dentate line was performed. Healing after ultrasonic mucosal proctectomy occurred without infection or retraction. Ultrasonic fragmentation offers an alternative to the standard technique of mucosal proctectomy. This new method is useful in those patients in whom separation of the rectal mucosal layer is difficult to perform.     

经肛门括约肌直肠肿瘤切除术97例临床疗效

目的探讨经肛门括约肌手术在中低位直肠肿瘤局部切除术中的作用和疗效。方法对1990年3月至2007年3月采用经肛门括约肌手术的97例中低位直肠肿瘤病例进行回顾性分析。结果全组行直肠部分切除术91例,直肠节段切除术6例。术后并发伤口感染5例（5．2％）,直肠皮肤瘘4例（4．2％）。术后病理结果为：直肠绒毛状腺瘤35例,直肠癌50例,直肠类癌等12例。直肠癌中Tis期17例,T1期21例,T2期7例,T3期2例,T4期3例。术后平均随访6．4年（2个月～16年）。术后肿瘤局部复发3例（6．2％）。术后3年和5年生存率分别为93．7％和87．5％。本组无手术死亡,无术后肛门失禁。结论经肛门括约肌直肠肿瘤局部切除术具有手术创伤小、风险低和易于保留肛门等优点,适用于中低位直肠肿瘤的治疗。