Treatment of lateral node metastasis from lower rectal cancer

Lateral lymphatics of the rectum originate in the area where branches of the inferior hypogastric plexus and the middle rectal vessels from the internal iliac vessels enter the mesorectum below the level of the peritoneal reflection in the pelvis, then reach the bifurcation of iliac vessels along the internal iliac vessels. Among lateral lymph nodes, the middle rectal, obturator, and internal iliac lymph nodes are important from the viewpoint of both the incidence of metastais and treatment effects. Although total mesorectal excision (TME) had become the standard surgical treatment for rectal cancer by the 1990s, this technique does not treat lateral node metastasis. A randomized clinical trial of TME versus D3 lymphadenectomy (JCOG0212) was started in 2003, and the registration of 701 patients with lower rectal cancer was completed in August 2010. The results of this clinical trial are highly anticipated. In Japan, where the rate of local recurrence after surgery is low, patients at high risk of local recurrence such as those with lateral node metastasis, T4 disease, and multiple lymph node metastases in the mesorectum should be selected to receive preoperative chemoradiation. Japanese surgeons who treat rectal cancers are in an advantageous position because they have the additional measure of lateral node dissection along with TME and chemoradiotherapy.     

Distal dissection in total mesorectal excision,and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4–5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.     

腹腔镜直肠癌前切除术

基于COLOR II等研究结果,腹腔镜直肠癌手术的地位得以逐步确立。手术切除是直肠癌最重要的治疗方法,对于上段直肠癌,前切除术是标准术式;对于中下段直肠癌,需遵循全直肠系膜切除(TME)的原则,选择低位前切除术或者腹会阴联合切除术。R0切除是手术治疗的核心要素,这包括两层含义:其一是淋巴结清扫范围需要达到D2水平,其二是标本的远、近端切缘以及环周切缘均需为阴性。准确地解剖出肠系膜下动脉、左结肠动脉以及直肠上动脉,是保证淋巴清扫范围的基础,循"神圣平面"解剖分离直肠系膜是环周切缘阴性和标本完整的保证。     

全直肠系膜切除术的应用

传统的直肠癌根治术后局部复发是影响术后5年生存率的重要因素之一。近年来解剖学研究证明，直肠是具有系膜的脏器，直肠癌可通过多种方式在系膜中播散，这些微转移灶的残留是导致术后局部复发的重要因素。1982年，Heald首次提出了针对中下段直肠癌的全直肠系膜切除术，即直视下在盆筋膜脏层与壁层间锐性分离，完整切除直肠及直肠系膜，同时注意保护自主神经。经过20年的应用，其在降低直肠癌术后复发方面的优势已得到认可，术后吻合口漏、排尿功能及性功能障碍等并发症发生率低，目前已得到广泛应用。     

Simplification of total mesorectal excision with colonic J-pouch anal anastomosis for middle and lower rectal cancer: One surgeon’s experience

PURPOSE: The introduction of total mesorectal excision (TME) has dramatically improved local control of rectal cancer. Yet, despite its complexity, there is no clear technical explanation of this procedure in the text references. Thus, we attempted to simplify the TME procedure according to its original concept. METHODS: Our procedure has three principles: posterolateral dissection, which is helpful for performing complete TME with autonomic nerve preservation; detachment of the hiatal ligament, which enables mobilization of the whole mesorectum and transection of the distal rectum just above the anal canal; and colonic J-pouch anal anastomosis to support fecal continence. We evaluated our modified TME, focusing on one surgeon's experience. RESULTS: Between 1993 and 2006, 164 patients underwent modified TME, performed by one surgeon (M.K.). Intraoperative blood loss and operating time were both significantly lower than for conventional resection (P < 0.01), and the rate of anastomotic leakage was less than 1%. Modified TME combined with radiotherapy or chemotherapy, or both, also improved prognosis considerably. CONCLUSION: We have succeeded in simplifying the original TME procedure and improved its outcome even further, based on our familiarity with its anatomyoriented elements.     

Advances in surgical treatment of rectal cancer

Increased understanding of the natural history of the disease, standardization of surgery and new procedures have led to significant advances in the treatment of rectal cancer. Anatomical dissection of the mesorectum permits optimal local control and volume cases may further improve oncological RESULTS: Autonomic pelvic nerves are preserved by the technique of total mesorectal excision (TME) and adapted anterior dissection plans improve preservation of genito-urinary functions. Sphincter preservation can be achieved by a conventional anterior resection for high and mid-rectal tumours, and by the technique of intersphincteric resection for low tumours. A J-pouch or a recently-designed coloplasty pouch must be associated with coloanal anastomoses in order to improve functional results and loop ileostomy is recommended to decrease early postoperative morbidity. Local excision constitutes an alternative to major surgery in patients with a low-risk early rectal cancer. Neoadjuvant treatments have a role in local control of the disease after TME surgery and in new strategies of sphincter-saving procedures. The place of anorectal reconstruction and that of laparoscopy are also discussed.     

头侧中间入路的腹腔镜直肠癌根治术

我们尝试采用头侧中间入路法以解决目前传统中间入路的一些不足。手术具体步骤包括:推开屈氏韧带处的空肠,切断该处附着的筋膜及韧带,将小肠肠袢完全推至右上腹部,显露屈氏韧带和左侧结肠系膜、腹主动脉及肠系膜下血管;从肠系膜下动脉(IMA)头侧的腹主动脉表面腹膜处打开进入左结肠后间隙,并顺势清扫IMA根部周围巴结;打开IMA尾侧的直乙结肠系膜并进入乙结肠后间隙,清扫IMA下方的周围淋巴结,并使乙结肠后间隙和左结肠后间隙贯通;显露IMA,肠系膜下静脉(IMV)和左结肠血管、乙结肠血管等相关血管,用血管夹夹闭离断相关血管根部,并可选择性的保留左结肠血管等。后续步骤同传统中间入路腹腔镜直肠癌根治术。     

腹腔镜直肠癌手术中神经血管束显露保护及其损伤防治

全直肠系膜切除的提出推动了结直肠外科进入膜解剖时代,极大降低了直肠癌的局部复发率及改善了泌尿及性功能的保护。但由于盆丛及神经血管束与直肠系膜间存在多处微血管及神经的支配关系,导致直肠系膜在侧前方及侧后方与盆壁均存在致密粘连,神经血管束被分为多层的Denonvilliers筋膜包裹及分割,Denonvilliers筋膜后叶向后与盆筋膜壁层的前叶相延续,盆筋膜壁层分层包绕腹下神经、盆丛及神经血管束,保护Denonvilliers筋膜后叶及盆筋膜壁层的完整性是保护神经血管束的重要原则,神经纤维周围有微血管并行,来自髂内血管系统走向直肠系膜的滋养血管具有不同于盆筋膜壁层表面微血管的走行特征,可作为辅助筋膜辨识的重要标志。适当的牵拉暴露、分离手法,优化的手术流程,熟悉筋膜解剖以及微血管对筋膜辨认的作用是避免神经血管束损伤的关键措施。     

直肠癌大组织切片系膜九分区法病理学研究

目的　探索直肠癌全直肠系膜切除术 (TME)的必要性和选择性全直肠系膜切除术(STME)的最佳切除范围。方法　以 31例直肠癌TME手术标本为对象 ,纵向由远及近以 5mm的间距连续取材 ,常规固定包埋 ,大组织切片机以 2 .5cm的间隔连续切片 ,HE染色 ,光学显微镜观察结果。将直肠系膜等分为内、中、外三个带 ,每带按左、右、后三个方向分为三个区 ,直肠癌在直肠系膜内的转移灶分别定位于上述九个区。结果　直肠系膜外带内癌转移 1 4例 (4 5 .2 % ) ,全部为低位直肠癌 ;远端直肠系膜 (DMR)内癌转移 2例 (6 .5 % ) ,均在原发灶下缘以远 3.0cm以内 ;环周切缘癌浸润 2例 (6 .5 % )。结论　低位直肠癌根治手术时 ,完整地切除直肠系膜非常必要 ;远端直肠系膜的切除应达到肿瘤下缘以远 4cm。     

Laparoscopic versus open total mesorectal excision for rectal cancer: An evaluation of the mesorectum’s macroscopic quality

BACKGROUND: Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated. METHODS: A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum. RESULTS: A three-grade scoring system showed no differences between the LTME and OTME groups. CONCLUSION: The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.     

Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma

Background

After total mesorectal excision (TME) surgery, patients with an incomplete mesorectum have an increased risk of local and overall recurrence. With the introduction of laparoscopic TME, an improved quality of the specimen was expected. However, the quality-related results were comparable to the results after traditional open surgery. Transanal TME is a new technique in which the rectum is mobilised by using a single-port and endoscopic instruments through the so called ‘down to up’ procedure. This new technique potentially leads to an improved specimen quality. This study was designed to investigate the pathological quality of specimens after transanal (TME) and to compare these with specimens after traditional laparoscopic TME.

Methods

This matched case control study compared the specimens of a cohort of consecutive patients who underwent transanal TME with the specimens after traditional laparoscopic TME. The pathological quality of the mesorectum was determined by the definitions of Quirke as ‘complete’, ‘nearly complete’, or ‘incomplete’.

Results

From June 2012 until July 2013, 25 consecutive patients underwent transanal TME because of a rectum carcinoma. Within the transanal TME group, 96 % of the specimens had a complete mesorectum, while in the traditional laparoscopic group, 72 % was deemed complete (p < 0.05). Other pathological characteristics, such as the circumferential resection margin, were comparable between the two groups.

Conclusions

Transanal TME appears associated with a significant higher rate of completeness of the mesorectum. Further studies are necessary to evaluate this novel technique.     

低位直肠癌常规行No.253淋巴结清扫的争议与共识

低位直肠癌是否常规行No.253淋巴结清扫,目前仍存在诸多争议,且东西方观点有所不同。西方学者更强调全直肠系膜切除（TME）,保证直肠系膜的完整性是手术根治的关键,良好的TME手术质量可降低局部复发率。对于T2以上的低位直肠癌日本学者和我国学者除了强调全直肠系膜切除外,还注重对肠系膜下动脉根部淋巴结（即No.253淋巴结）的清扫（D3根治术）。近年来,低位直肠癌是否常规行No.253淋巴结清扫观点趋于统一：如怀疑No.253淋巴结转移,建议行新辅助化疗,或术中行快速冰冻病理学检查,如证实No.253淋巴结转移则进行彻底的清扫。对于分期在T2以内的低位直肠癌,若术前检查和术中探查No.253淋巴结阴性则不作为低位直肠癌的常规清扫范围,因为在清扫No.253淋巴结时很容易损伤腰内脏神经和肠系膜下神经丛,造成术后泌尿生殖功能障碍。多数学者认为对于T2以内的低位直肠癌不常规行No.253淋巴结清扫,而对于T3以上的低位直肠癌如术前检查怀疑No.253淋巴结发生转移,则更强调新辅助放化疗联合TME及行No.253淋巴结清扫的D3根治术。     

TOTAL MESORECTAL EXCISION: EVALUATING THE EVIDENCE

The present paper reviews information from pathological and clinical studies examining the role of total mesorectal excision (TME) in the treatment of rectal cancer. The pathological studies provide information about the spread of rectal cancer within the mesorectum, and the adequacy of excision obtained with conventional surgery and TME. The clinical studies provide information about the safety of TME and the reported local recurrence rates. Taken together, these studies provide a rationale for using TME to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from randomized controlled trials.     

Adjuvant radiotherapy in rectal cancer and total mesorectal excision

Local recurrence (LR) after surgical resection for adenocarcinoma of the rectum still remains an unsolved problem. Local relapse often occurs when tumor spreads in perirectal fat (mesorectum) or along the lateral iliac lymph nodes also when surgery is considered radically. There is a close relationship between local recurrence rate and lymphatic involvement, local tumor extension and tumour grading. Total mesorectal excision (TME) appears to be associated with a reduced LR rate when resection of perirectal fat is done "en-bloc" and when a negative radial margins is obtained. TME allows autonomic nerve sparing and sphincter preservation too, but lateral nodes are not treated by TME. Extended lymphadenectomy with lateral dissection for advanced rectal cancer has been often associated with an increase rate of long term morbidity, particularly regarding urinary and sexual function. Concomitant preoperative chemo-radiation for advanced rectal cancer is a relatively safe procedure with an acceptable morbidity and mortality. This approach is associated with a considerable clinical and pathologic tumor downstaging. Tumor resectability is improved and lateral spreading is also better controlled. An improving in survival and a longer disease free period has been reported. More radical sphincter saving operations are also allowed.     

Patterns of neoplastic foci and lymph node micrometastasis within the mesorectum

Background and aims Local recurrence after rectal cancer surgery is conceived to result from microscopically incomplete resection. We aimed to investigate the patterns of mesorectal neoplastic foci, and examined the involvement and micrometastasis of lymph nodes.Methods Observation of large tissue slice and analysis of tissue microarray were integrated in the pathological study of 31 total mesorectal excision (TME) specimens.Results Altogether, 349 mesorectal neoplastic foci were examined from 18 specimens. Almost 33% of them were in the outer layer of mesorectum. Concerning position of primary tumor, ipsilateral neoplastic foci were significantly more than contralateral neoplastic foci. Distal mesorectal spread was found in four patients with the distance ranging from 1 to 3.5 cm. Four specimens were diagnosed to have circumferential margin involved. Nine hundred seventy-two lymph nodes were harvested with 128 involved by tumor. No significant difference in occurrence of micrometastasis was observed among tumors of different stage.Conclusions Combination of large tissue slice and tissue microarray provided a more detailed method in studying the metastasis of rectal cancer. Complete excision of the mesorectum with fascia propria circumferentially intact is essential. Circumferential margin involvement and micrometastasis suggested that tumor spread may go beyond the scope of a single TME procedure.     

腹腔镜全直肠系膜切除术治疗中低位直肠癌35例报告

目的:探讨腹腔镜全直肠系膜切除术(total mesorectum excision,TME)的手术技巧及应用价值.方法:回顾分析为35例患者施行腹腔镜全直肠系膜切除术的临床资料.结果:35例患者均按TME 原则完成腹腔镜直肠癌手术,平均清扫淋巴结(10.7±5.3)枚,手术时间平均150min,术中出血量10～30m...     

进展期直肠癌淋巴结转移状况与根治术的关系

研究进展期直肠癌淋巴结转移状况,指导手术根治范围。方法：76例直肠癌患者行D3式根治术,按肿瘤旁、肠管纵轴和中枢方向行淋巴结分组,检测侧方和腹膜返折下直肠周围系膜转移淋巴结数,并计算淋巴结转移率。结果：肿瘤旁和肠管纵轴方向边缘动脉旁淋巴结转移率分别为39.5%和9.2%,肛侧端距肿瘤2cm未见转移;沿肠系膜下血管中枢方向淋巴结转移率为18.4%,而肠系膜下动脉(IMA)根部淋巴结转移率为10.5%;侧方淋巴结转移率为11.8%,腹膜返折下直肠周围系膜淋巴结转移率为12.5%。结论：进展期直肠癌可向肠管纵轴和中枢方向淋巴结转移。腹膜返折下直肠癌有侧方淋巴结转移并侵及直肠周围系膜,肿瘤浸润深度超过pT2期和低分化癌者淋巴结转移相应增多。宜行IMA根部结扎整块切除的D3式廓清术,腹膜返折下直肠癌力争行侧方淋巴结清扫和全直肠系膜切除术。     

Modern rectal cancer surgery—Total mesorectal excision—The standard of care

The literature has repeatedly shown the superiority of total mesorectal excision (TME) for rectal cancer in reducing the incidence of local recurrence (LR) and improving long-term survival compared to conventional blunt rectal dissection. This article reviews the history of surgery for rectal cancer, supports TME as the standard of care in obtaining a negative circumferential margin (CRM) for mid- and lower-third rectal cancers, discusses the drawbacks of TME, the role of tumor-specific mesorectal excision for upper-third rectal cancers and laparoscopic TME, and emphasizes the need for a selective role of chemoradiation with TME for rectal cancer. The need for standardizing TME in the United States with pathological specimen quality analysis and reporting of the completeness of the TME specimen is also emphasized.     

TAMIS-assisted laparoscopic low anterior resection with total mesorectal excision in a cadaveric series

Background

To demonstrate the feasibility of an innovative technique for the surgical management of rectal cancer, we performed transanal minimally invasive surgery assisted low anterior resection with total mesorectal excision (TAMIS-assisted LAR with TME) in a cadaver model. Transanal LAR via natural orifice transluminal endoscopic surgery has been reported in cadaveric series using rigid transanal platforms. This procedure has not been described using a combination of a single incision laparoscopy and TAMIS transanal endoscopic platform. We describe the first cadaveric series of TAMIS-assisted LAR with TME.

Methods

TAMIS-assisted LAR with TME was successfully performed in five fresh human cadavers. The procedure was performed using the mini-Gelpoint single incision platform and the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA). The variables recorded were age, body mass index (BMI), operative time, complications, and specimen length. The grade of the TME was determined by evaluation of the specimen by photo documentation by a gastrointestinal pathologist.

Results

All cadavers were male with a mean age of 71 ± 8 years and mean BMI of 28 ± 3 kg/m². The mean operative time was 200 ± 55 min (range 128–249 min). The quality of the TME was grade I (complete) with intact mesorectum in all five cases. The mean specimen length was 36.8 ± 3.4 cm.

Conclusions

TAMIS-assisted LAR with TME was feasible. A high-quality TME can be achieved using this innovative technique. Transanal endoscopic total mesorectal dissection may revolutionize the surgical management of rectal cancer. However, multicenter clinical trials are needed to further evaluate the oncologic safety and surgical outcomes of transanal endoscopic TME using various platforms before widespread application of this new technique.     

腹腔镜全直肠系膜切除术保肛治疗低位直肠癌

目的:探讨腹腔镜全直肠系膜切除术(total mesorectal excision,TME)行低位(超低位)直肠癌保肛治疗的方法与可行性。方法:按TME原则,用双吻合器技术在腹腔镜下对26例低位(超低位)直肠癌患者实行TME低位(超低位)结肠-直肠(肛管)吻合术。结果:手术均获成功,无中转开腹,手术时间180-240min,平均210min;术中出血30-100ml,平均70ml;术后2d恢复胃肠功能并下床活动;住院7-14d,平均8d,无严重并发症发生。结论:腹腔镜TME低位(超低位)吻合术保肛治疗低位直肠癌具有创伤小、并发症少、出血少、肠功能恢复快等优点,安全可行。