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The neurovascular bundle (NVB) starts at the lateral angle of the seminal vesicle (the initial part), passes posterolateral of the prostate gland (the main part), and ends at the cavernous body of the penis (the cavernous part). In low rectal surgery, different transabdominal and transanal perspectives result in different NVB injury risks. In the perspective of transabdominal operation, the separation between the initial part of NVB and Denonvilliers fascia and the anatomical variation of the two lateral sides of Denonvilliers fascia increases the risk of NVB injury, and conformation separation may take into account the convenience of separationand the protection of NVB. In the perspective of transanal operation, when separating the main part with NVB and mesorectum, the perspective of the transanal, unidirection traction and excessive dissection increase the risk of NVB main exposure. Clear anatomical identification helps the protection of NVB in the transanal operation. At present, the medical evidence on the difference of NVB injury in different perspectives of transabdominal and transanal approach is still in need of relevant clinical researches.
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Whether the transanal total mesorectal resection (taTME) techniques increase the risk of anastomotic failure is inconclusive. This paper discusses the anastomotic problems of taTME from different aspects including anatomical factors and technical characteristics. In terms of the anatomic and physiological characteristics of the lower rectum, the Hiatal ligament and the density of the perirectal space is a disadvantage to the anastomosis of taTME, while the prolapse of the rectum may be a beneficial factor. Due to the unique technical characteristics of taTME, the main reason affecting its anastomosis at present is that the caudal space at the distal end is not sufficiently mobilized, especially for male and lower anastomosis. In addition, stapled anastomosis at the level of anorectal ring may cause more problems, while manual anastomosis at the lower level may bring better results.
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In recent years, transanal total mesorectal excision (taTME) has become one of the focuses of colorectal surgery, but it still faces some controversial problems that have not been solved, such as urethral injury as a typical complication. This paper, from the perspective of urological and rectal surgery respectively, elucidates the current research progress on the anatomy between the rectum and urethra. From the perspective of urethral anatomy, the main structure involving urethral injury in taTME surgery is the rectourethral muscle, which actually is part of the longitudinal muscle of the rectum from the perspective of rectal anatomy. Summarizing existing research results, the authors propose a new perspective about the key anatomical structure of hiatal ligament. As a matter of fact, hiatal ligament is the branch of longitudinal muscle of the rectum which circles the rectum, and the thickest part is at the center of the front and back respectively, then becomes thinner gradually to the 1 o'clock and 11 o'clock position. The front part of the hiatal ligament is just named as rectourethral muscle for urology surgery. On this basis, when taTME surgery is performed, it is recommended to follow the principle of " lateral first, center later" , that is, the thin lateral parts of hiatal ligaments is separated first, then the thick central parts after entering the familiar space. If necessary, the position of urethra and prostate can be confirmed through digital rectal examination, fluorescence catheter or other navigating methods. This paper aims to promote further development and popularization of taTME by introducing relevant anatomy of taTME surgery and various methods to avoid urethral injury.
Subject(s)
Humans , Male , Digestive System Surgical Procedures , Rectal Neoplasms , Rectum , General Surgery , Transanal Endoscopic SurgeryABSTRACT
Objective To investigate the short-term safety of raltitrexed intraperitoneal perfusion in patients with rectal cancer undergoing laparoscopic Dixon surgery.Methods Totally 175 patients with rectal cancer at the Department of Colorectal Oncological Surgery,Shengjing Hospital of China Medical University were analyzed retrospectively from June 2016 to December 2017.All the patients were divided into raltitrexed intraperitoneal perfusion group (n =89) and saline intraperitoneal peffusion group (n =86) according to whether given raltitrexed intraperitoneal perfusion or not.The hematological indexes of the two groups before operation and 3 days after operation were recorded.The postoperative exhaust time and postoperative drainage volume within 24 hours were calculated.The postoperative complications including anastomotic leakage,peritoneal irritation sign,incision infection and pulmonary infection were evaluated.Results The surgery was performed successfully in all patients.There were no significant differences in the sex (x2 =0.000,P =0.990),depth of tumor invasion (x2 =0.003,P =0.956),degree of lymph node metastasis (Z =-0.590,P =0.556),TNM stage (Z =0.081,P =0.936) or pathological type (Z =1.092,P =0.896) between the two groups.There were no significant differences in postoperative exhaust time [(75.49 ± 3.97) h vs.(74.28 ±3.46) h,t =0.479,P =0.523],postoperative drainage volume within 24 hours [(201.1 ±54.1) ml vs.(242.8±25.7) ml,t=0.338,P=0.656],anastomotic leakage (1.1％ vs.2.3％,x2 =0.351,P=0.554),peritoneal irritation sign (1.1％ vs.2.3％,x2 =0.351,P =0.554),incision infection (2.2％ vs.3.5％,x2 =0.243,P =0.622) and pulmonary infection (2.2％ vs.2.3％,x2 =0.001,P =0.972) between the two groups.Additionally,there were no significant differences in the counts of erythrocytes [(3.56 ±0.27) × 1012/L vs.(3.63 ±0.26) × 1012/L,t =0.716,P =0.152],leukocytes [(7.63 ±0.20) x 109/L vs.(8.24 ±0.26) × 109/L,t =0.176,P =0.872],blood platelets [(170.13 ±20.12) × 109/L vs.(180.18 ±21.03) × 109/L,t =0.103,P =0.975],glutamic-pyruvic transaminase [(13.25 ± 2.31) U/L vs.(13.28 ± 1.46) U/L,t =0.321,P =0.713],glutamic-oxalacetic transaminase [(16.51 ± 1.28) U/L vs.(16.23 ±2.03) U/L,t=0.131,P=0.894] and creatinine [(77.36 ±6.49) μmol/L vs.(78.39 ±6.64)μmol/L,t =0.499,P =0.519] 3 days after operation between the two groups.Conclusion Raltitrexed intraperitoneal perfusion in Dixon surgery exhibits high safety,and no significant effect on postoperative recovery.It is easy to operate and has good feasibility,which is worthy to be used in clinic.
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Objective To explore the relationship between the expression levels of excision repair cross complementation group 1(ERCC1), breast cancer susceptibility gene 1(BRCA1), thymidylate synthase (TS) mRNA and clinicopathological features, prognosis in advanced colorectal cancer, and the correlation between the expression levels of ERCC1 and BRCA1. Methods The expression levels of ERCC1, BRCA1 and TS mRNA of postoperative paraffin embedded tissue were tested by real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) in 49 advanced colorectal cancer cases. The results were analyzed by χ2 test of the correlation between the expression levels and clinicopathological characteristics. Patients were followed up by clinic or telephone. The prognosis was analyzed by small sample Kaplan-Meier survival analysis and Log-rank time series analysis, and P0.05). The expression level of BRCA1 mRNA had no significant correlation with the above clinical and pathological features (P>0.05) except distant metastasis (P=0.030) and differentiation degree (P=0.002). The expression level of TS mRNA had no significant correlation with the above clinical and pathological features (P>0.05) except distant metastasis (P=0.003). The expression level of ERCC1 and BRCA1 mRNA obviously correlated (P=0.002). The 1 year overall survival rate was 95.92%(47/49);the 2 year overall survival rate was 83.67%(41/49);and the 3 year overall survival rate was 73.47%(36/49). Overall survival and progression-free survival time in ERCC1 mRNA low expression group (47.8, 41.0 months) was higher than that in ERCC1 mRNA low expression group (27.3, 20.0 months) respectively (P=0.001, P=0.001). Overall survival and progression-free survival time in BRCA1 mRNA low expression group (43.7, 42.7 months) was higher than that in BRCA1 mRNA high expression group (29.3, 25.1 months) respectively (P=0.009, 0.006). Overall survival time in TS mRNA low expression group (39.8 months) was higher than that in BRCA1 mRNA high expression group (25.2 months). Conclusions The expression level of ERCC1 mRNA is not correlated with its clinical and pathological characteristics, but with its biological characteristics. BRCA1 and TS levels are correlated with invasion and metastasis. Low levels of ERCC1 and BRCA1 expression have a better prognostic effect on platinum based first-line chemotherapy for advanced colorectal cancer, and they are correlated. Low level of TS also has longer disease-free survival. Three joint detection could be used as a prognostic factor for colorectal cancer chemotherapy.
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Objective:To evaluate the effects of neoadjuvant chemoradiotherapy on anal function after intersphincteric resection (ISR) with low rectal cancer. Methods:A total of 103 patients were classified into the chemoradiotherapy (CRT) group and control group according to whether they received neoadjuvant chemoradiotherapy. Anal function was assessed using vectorial manometry, Saito function questionnaires, and Wexner incontinence scores. Results:The resting vector volume and squeezing vector volume of the CRT group were significantly lower than those of the control group prior to the operation. Both groups showed decreasing manometric re-sults after ISR. However, all indices of the CRT group were significantly lower than those of the control group (P<0.05). At 6 and 12 months after operation, the Saito questionnaire results reveal poor function for the CRT group compared with the control group, except for dyschesia. After 24 months, the stool frequency, ability to distinguish between feces and flatus, fragmentation, and alimentary re-striction remained poor for the CRT group (P<0.05). Although both groups showed decreasing Wexner scores with time, the score of the CRT group remained significantly higher than that of the control up to 24 months after operation. Conclusion:Neoadjuvant chemo-radiotherapy significantly affects the anal sphincter function for intersphincteric resection with low rectal cancer. This effect continues for at least 2 years after operation.
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Objective To detect the correlation of serum p53 antibody and p53 protein expression of cancer tissue in patients with colorectal cancer (CRC), and to evaluate if the serum p53 antibody might reflect the mutation of p53 gene in CRC. Methods One hundred and thirty-two patients with CRC and 36 patients with non-tumor disease were included in this prospective study. The presence of serum p53 antibody was determined by enzyme-linked immunosorbent assay (ELISA). Immunohistochemical analysis of tumors was performed to detect the accumulation of p53 protein. Results The positive rate of p53 antibody was 40.2% in patients with colorectal cancer and 2.9% in non-tumor patients,( P
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Objective To evaluate the results of anal function and oncologic effect of intersphincteric resection(ISR) for very low rectal cancer Methods Sixteen patients who had ISR from March 1999 to March 2006 in our hosptal.After complete dissection of the rectum and mesorectum down to the pelvic floor,the internal sphincter was separated from the external sphincter and puborectalis and resected together with the rectum,then the coloanal anastomosis was performed.On postoperative day 7,the anal contraction function training was started;on week 4,biofeedback training was started;on week 2,chemotherapy was used for Dukes B,C stage,and on week 4 radiotherapy was used.Results There was no operative mortality,and no anastomotic leakage.Colonic mucosa prolapse developed in two patients,two developed late strictures of the coloanal anastomosis and one had wound problem.At follow-up of 3 months to 7 years,there were 2 deaths from liver metastasis and 1 death from lung metastasis;no patient developed local recurrence.According to Williams continence status level,acceptable postoperative anal function were obtained in 62.5 %,80.0 %,and 84.6 % of patients at 3,6,and 12 months respectively.Conclusions ISR is safe for selected patients with very low rectal tumor,operative morbidity is low,and the curability rate and anal functional results are satisfactory.
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Objective To investigate the outcome of low anterior resection of rectal cancer with double stapling technique.Methods A retrospective analysis of clinical records of 78 rectal cancer patients who had anal preservation operation using double stapling technique was performed.Results In all of the cases,the rectal closing and anastomosis were satisfactorily completed.All the resection margins were negative for tumor infiltration.There was no operative mortality or anastomosis leakage.Seventy-three(93.6%)cases were followed up for 9-65 months,pelvic recurrence occurred in 2 cases(2.7%),multiple metastasis of peritoneal cavity occurred in 1 case(1.4%),liver metastasis was found in 7 cases(9.6%),one patient suffered from local recurrence and Miles operation was performed 11 months later.Conclusions Double stapling technique can provide more chances for sphincter preservation operation in patients with lower rectal cancer.If the technique is properly used,it also may effectively reduce the rate of anastomosis leakage and other complications.