The modern abdominoperineal excision : The next challenge after total mesorectal excision

摘要: Total mesorectal excision (TME) involves sharp dissection in the plane that separates visceral fascia from parietal pelvic fascia. Surgical techniques aimed at TME and removal of tissue, including rectal carcinoma as a “tumor package,”1–3 have been widely adopted, with improved patient outcome. For example, Swedish study involving surgical training, local recurrence rate 6% is reported patients who underwent compared 14% 15% control groups (P < 0.0001).4 In national Norwegian audit 3319 new patients, technique was conventional surgery. The observed for undergoing curative resection group treated by 12% surgery group, while 4-year survival 73% after 60% surgery.5 large multicenter trial coordinated Dutch ColoRectal Cancer Study Group has used standard procedure examining benefits short-course preoperative radiotherapy excision.6 Early published indications (24 month follow-up) are plus (RT) associated lower (2.4%) than alone (8.2%) macroscopically complete resection.7 Recently presented data show these risen to 5.8% 11.4% 4.83 years median follow up (van de Velde C, personal communication). rates APR were 9.3% 14%. Preoperative RT considered safe surgery, despite slight increase complications when only.8 Abdominoperineal resections (APRs) high anterior (ARs).3 Possible reasons include higher incidence inadequate APR, or lymph node involvement may different pattern low carcinomas. unit pioneered TME, series 136 operations third rectum (below 5 cm anal verge) included 31 excisions (23%), considerably 6-year corresponding AR (33% versus 1% procedures).3 One aims our investigate had undergone procedures over 12-year period 1986 1997, assess effect change specifically its impact on APR. this operating surgeon previously.9 The mesorectum mesentery surrounding covered layer Distally, tapers reveal muscle internal sphincter, “holy plane” perimesorectal advocated Heald ends intersphincteric between external sphincters.10 smooth tube colo-anal anastomosis, but cases be transected4 would not total. allows down floor, thus facilitating anastomosis sphincter-preservation well visualization preservation nerves. introduction resulted significant reduction carcinoma, being “gold standard” much 20th Century necessary perhaps patients.2 Stockholm project,4 there significantly proportion (27%) non-TME (55% 60%). Assessment specimen following includes examination circumferential margin (CRM) tumor involvement, which increased survival,9,11 This demonstrated an analysis Registry (n = 686), showed 22% CRM+ (margin ≤1 mm) 5% CRM-negative cases.12 Similar emerged TME/TME trial,13 only difference their claim 2-mm also indicated risk. Assessment macroscopic assessment completeness resection, overall 2-year follow-up found worse incomplete 0.01).14 negative CRM, (28.6% 14.9%, P 0.03), hence additional value without CRM involvement. Abdominoperineal particularly poorly excised, 34% showing resections.14 However, assessed whole did separate quality canal dissections, making it impossible determine relative importance each individual cause APRs. In view documented cases, we designed using morphometry compare specimens identify frequency risk It laboratory practice subsequently recommendation United Kingdom Royal College Pathologists (http://www.rcpath.org/index.php?PageID=229) leave bowel intact level during fixation, allowing serial slicing fixed margin. several advantages direct comparison magnetic resonance imaging effective otherwise destroyed opening process. Photography transverse slices routine, digital images taken 1997 2000 provided archive retrospective primary image analysis. results obtained characterize differences specimens, CRM-positive specimens.