Perspectives on Intravenous Oxycodone for Control of Postoperative Pain.

Intravenous (IV) analgesia has particular advantages in the immediate postoperative period. For example, IV administration results in a faster onset of pain relief and results in more predictable pharmacokinetics than does administration by other routes. It also allows for convenient dosing before or during surgery, permitting the initiation of effective analgesia in the early phase of the postoperative period. In addition, when patients are able to tolerate oral intake, they can be switched from IV to oral dosing based on maintaining the predictable analgesia established by the IV route. IV morphine is widely used for the control of postoperative pain, but there is a trend toward the use of oxycodone. Oxycodone (which may be mediated partly through kappa- as well as mu-opioid receptors) offers several potential advantages. Published studies comparing IV oxycodone to other IV opioids for postsurgical pain report that oxycodone is a safe and effective analgesic. Some studies show that IV oxycodone may be associated with greater pain control, fewer or less severe adverse events, and faster onset of action, although the results are not consistent across all studies. Oxycodone has been reported to be safe in the geriatric and other special populations when adequate clinical adjustments are made. Thus, the clinical reports and oxycodone's pharmacologic profile make intravenous oxycodone a potentially important "new" old drug for postoperative pain control.

On the correct lectotype for Marmessoidea unicolor Redtenbacher, 1908 (Insecta: Phasmatodea).

Hennemann, F.H., Conle, O.V. & Brock, P.D. (2023) The types of Phasmatodea (= Phasmida) deposited in the Eidgenssisches Technisches Hochschulzentrum, Zrich, Switzerland (ETHZ). Zootaxa, 5278 (1), 176188. https://doi.org/10.11646/zootaxa.5278.1.10 Hovinga, H. (2010) The Sumatra Railroad: Final destination Pakan Baroe, 19431945. Brill, Leiden, 391 pp. https://doi.org/10.1163/9789004253711 ICZN [International Commission on Zoological Nomenclature] (1999) International Code of Zoological Nomenclature. International Commission of Zoological Nomenclature. 4th Edition. Adopted by the XXI General Assembly of the International Union of Biological Sciences. International Trust for Zoological Nomenclature, in association with the British Museum (Natural History), London, 338 pp. Redtenbacher, J. (1908) Die Insektenfamilie der Phasmiden. III. Phasmidae Anareolatae (Phibalosomini, Acrophyllini, Necrosciini). Wilhelm Engelmann, Leipzig, pp. 341589, pls. 1627. Seow-Choen, F. (2021) A Taxonomic Guide to Stick Insects of Peninsular Malaysia. Vol. 1. Natural History Publications, Borneo, Kota Kinabalu, 944 pp. Weidmann, W. (1936) Der Schweizer als Pionier und Kolonist in Sumatra. In: Der Schweizer Verein Deli-Sumatra (Ed.), Der Schweizer Verein Deli-Sumatra: Zum fnfzigjhrigen Bestehen, 18861936. Buchdruckerei der Neuen Zrcher Zeitung, Zrich, pp. 3348.

Posterior perineal support as treatment for anal fissures--preliminary results with a new toilet seat device.

BACKGROUND: Anal fissures can cause morbidity in an otherwise healthy young patient. The process of evacuation results in stretching and descent of the anoderm and perineum especially posteriorly. Posterior perineal support may provide counter pressure at the posterior aspect of the pelvic floor, balancing the pressure exerted by the faeces on the anal wall, thus improving evacuation and reducing the trauma associated with it, and reducing symptoms of anal fissures. Symptoms of constipation may also be reduced secondarily. We report the preliminary results with a novel, simple and noninvasive method of treatment provided by a toilet seat device. METHODS: A prospective study was performed in 32 patients. The study was designed mainly to investigate the patients' subjective perceptions of their symptoms related to anal fissures and constipation. Questionnaires were provided to patients before, during and after treatment. RESULTS: The study revealed statistically significant improvement in pain, bleeding, symptoms of constipation and abdominal discomfort after 3 months usage of the device. The odds of patients perceiving an improvement in symptoms were also significantly increased after 3 months of treatment compared to 2 weeks of treatment. CONCLUSION: This preliminary study revealed that a posterior perineal support device can bring about significant improvement in the symptoms of patients with anal fissures. There may also be secondary benefits of a reduction in the symptoms of constipation. Although not conclusive, these results should serve as a springboard for further research into this area.

Fiber and colorectal diseases: separating fact from fiction.

Whilst fruits and vegetables are an essential part of our dietary intake, the role of fiber in the prevention of colorectal diseases remains controversial. The main feature of a high-fiber diet is its poor digestibility. Soluble fiber like pectins, guar and ispaghula produce viscous solutions in the gastrointestinal tract delaying small bowel absorption and transit. Insoluble fiber, on the other hand, pass largely unaltered through the gut. The more fiber is ingested, the more stools will have to be passed. Fermentation in the intestines results in build up of large amounts of gases in the colon. This article reviews the physiology of ingestion of fiber and defecation. It also looks into the impact of dietary fiber on various colorectal diseases. A strong case cannot be made for a protective effect of dietary fiber against colorectal polyp or cancer. Neither has fiber been found to be useful in chronic constipation and irritable bowel syndrome. It is also not useful in the treatment of perianal conditions. The fiber deficit - diverticulosis theory should also be challenged. The authors urge clinicians to keep an open mind about fiber. One must be aware of the truths and myths about fiber before recommending it.

Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades.

The advent of total mesorectal excision (TME) together with minimally invasive techniques such as laparoscopic colorectal surgery and robotic surgery has improved surgical results. However, the incidence of bladder and sexual dysfunction remains high. This may be particularly distressing for the patient and troublesome to manage for the surgeon when it does occur. The increased use of neoadjuvant and adjuvant radiotherapy is also associated with poorer functional outcomes. In this review, we evaluate current understanding of the anatomy of pelvic nerves which are divided into the areas of the inferior mesenteric artery pedicle, the lateral pelvic wall and dissection around the urogenital organs. Surgical techniques in these areas are discussed. We also discuss the results in functional outcomes of the various techniques including open, laparoscopic and robotic over the last 30 years.

Revision of the Oriental subfamily Heteropteryginae Kirby, 1896, with a re-arrangement of the family Heteropterygidae and the descriptions of five new species of Haaniella Kirby, 1904. (Phasmatodea: Areolatae: Heteropterygidae).

The areolate Oriental family Heteropterygidae Kirby, 1893 is critically reviewed and the results of the present study contradict the arrangement suggested by Zompro (2004), but in most aspects agree with a molecular study presented by Whiting et al (2003) and a phylogenetic study presented by Bradler (2009). The family is critically discussed and new hypotheses are presented for the phylogeny and intra-familiar relationships, placing the subfamily Dataminae Rehn & Rehn, 1939 as the basalmost clade of Heteropterygidae. The subfamilies Obriminae Brunner v. Wattenwyl, 1893 and Heteropteryginae Kirby, 1893 together represent the sister-group of Dataminae. Arguments and a tree are presented to support this hypothesis. New diagnoses and lists of genera are provided for all three subfamilies contained in Heteropterygidae, along with keys to distinguish between them.        The subfamily Obriminae is critically reviewed and the distinction between the three tribes Obrimini Brunner v. Wattenwyl, 1893, Eubulidini Zompro, 2004 and Miroceramiini Zompro, 2004 introduced by Zompro (2004) is shown to be poorly supported. While Obrimini sensu Zompro, 2004 is generally accepted (but now also contains genera that were placed in Eubulidini or Miroceramiini by Zompro (2004)), the tribes Eubulidini and Miroceramiini are not supported. A new arrangement is introduced, which is based on morphological characters neglected or overlooked by Zompro (2004) but were partly discussed by Bradler (2009). The genus Mearnsiana Rehn & Rehn, 1939 is removed from Miroceramiini and transferred to Obrimini. The genera Eubulides Stål, 1877, Heterocopus Redtenbacher, 1906, Theramenes Stål, 1875 and Stenobrimus Redtenbacher, 1906 are removed from Eubulidini and also transferred to Obrimini. Consequently, Eubulidini is synonymised with Obrimini (n. syn.). Miroceramiini is a monotypical tribe and only includes the Wallacean genus Miroceramia Günther, 1934. The new tribe Tisamenini n. trib. is established for the three basal genera Tisamenus Stål, 1875, Ilocano Rehn & Rehn, 1939 and Hoploclonia Stål, 1875 all of which were placed in Eubulidini by Zompro (2004). The latter genus differs from the other two genera by the morphology of the female genitalia, which is unique amongst the entire family. Three generic groups are recognized within Obrimini, the Obrimus-group, Stenobrimus-group and Theramenes-group. Keys are presented to distinguish between the three tribes now contained in the Obriminae, i.e. Obrimini, Tisamenini n. trib. and Miroceramiini. The genus Hennobrimus Conle, 2006 is synonymised with Mearnsiana Rehn & Rehn, 1939, based on the fact that the type-species of both genera are conspecific (n. syn.). Hennobrimus hennemanni Conle, 2006, the type-species of Hennobrimus, and Trachyaretaon manobo Lit & Eusebio, 2005 are synonymised with Mearnsiana bullosa Rehn & Rehn, 1939, the type-species of Mearnsiana (n. syn.). Theramenes dromedarius Stål, 1877 from the Philippines is removed from synonymy with the Wallacean Theramenes olivaceus (Westwood, 1859) and re-established as a valid species (rev. stat.).        The subfamily Heteropteryginae Kirby, 1896 is revised at the species-level and a new diagnosis is presented. Keys to the two genera and all 16 known species are provided along with new descriptions, differential diagnoses, lists of examined material, detailed information on the known distributions, measurements and illustrations of the insects and eggs. The intra-subfamiliar and intra-generic relationships are discussed and a cladogram is presented. Heteropteryginae contains two genera: Heteropteryx Gray, 1835 (Type-species: Phasma dilatatum Parkinson, 1798) and Haaniella Kirby, 1896 (Type-species: Phasma (Heteropteryx) muelleri de Haan, 1842). The distribution of this subfamily is restricted to Sundaland with the exception of a single species that is found in Vietnam. All other species are distributed in Borneo, Sumatra, the Mentawai Islands, Singapore, Peninsular Malaysia and Thailand. Heteropteryginae contains the largest and most striking members of the entire family Heteropteryginae, some of which are amongst the heaviest insects known. The subfamily is characterized by apomorphies such as the presence of wings, having a tympanal area (= stridulatory organ) in the basal portion of the alae, straight profemora, strongly shortened tarsi, lack of rough sensory-areas on the prosternum and typically X-shaped micropylar plate of the eggs. The sister-group of Heteropteryginae is represented by the Obriminae, with which it shares a beak-like secondary ovipositor in the females and presence of a medio-apical spine on the area apicalis. Both features are synapomorphies of Heteropteryginae + Obriminae.        The genus Haaniella Kirby, 1904 contains 16 known species, five of which are newly described herein. The genus Miniopteryx Zompro, 2004 (Type-species: Haaniella parva Günther, 1944) is synonymised with Haaniella on the basis that the distinguishing feature mentioned in the original description is a character that is frequently found throughout the genus (n. syn.). The type-species H. parva Günther, 1944 is automatically retransferred to Haaniella (rev. stat.). Haaniella aculeata n. sp. from western Sumatra is described from the male. Haaniella macroptera n. sp. from Singapore and the Johor state in southern Peninsular Malaysia is described from both sexes and the eggs. Haaniella gintingi n. sp. from Central Sumatra is described from both sexes and the eggs and Haaniella kerincia n. sp. from Western Sumatra is described from the insects only, the eggs being still unknown. One new species, Haaniella gorochovi n. sp., is the only representative of the genus and subfamily Heteropteryginae known from Vietnam and both sexes as well as the eggs are described. Haaniella erringtoniae (Redtenbacher, 1906) is endemic in Peninsular Malaysia, here removed from synonymy with H. muelleri (de Haan, 1842) and re-established as a valid species (rev. stat.). The Sumatran Haaniella glaber (Redtenbacher, 1906) is removed from synonymy with H. muelleri (Haan, 1842) and re-established as a valid species (rev. stat.). Leocrates glaber Redtenbacher, 1906 and Haaniella muelleri simplex Günther, 1944 are removed from synonymy with H. muelleri (Haan, 1842) (rev. stat.) and synonymised with H. glaber. Haaniella mecheli (Redtenbacher, 1906) and H. rosenbergii (Kaup, 1871) are removed from synonymy with H. muelleri (Haan, 1842) and re-established as valid species (rev. stat.). Haaniella erringtoniae novaeguineae Günther, 1934 and Haaniella muelleri var. b. (Haan, 1842) are synonymized with H. rosenbergii (Kaup, 1871) (n. syn.). The type-species Haaniella muelleri (Haan, 1842) is shown to be a fairly rare species that is restricted to Sumatra. All subsequent records of H. muelleri from outside Sumatra and references to captive breeding of stock originating from Peninsular Malaysia in Europe relate to H. erringtoniae (Redtenbacher, 1906). The previously unknown males and eggs of H. rosenbergii (Kaup, 1871) as well as the previously unknown females and eggs of H. parva Günther, 1944 are described and illustrated for the first time. Based on morphological characters of the insects and eggs three distinct species-groups are recognized within Haaniella. The muelleri species-group contains nine species that are distributed throughout Sumatra, the Mentawei Islands, Singapore and Peninsular Malaysia. These are characterized by the smooth ventral surface of the meso- and metafemora and lemon-shaped eggs which entirely lack the setae seen in the two other species-groups. The grayii species-group comprises four species, two of which are endemic in Borneo, one endemic in Sumatra and the fourth species being the only known representative of the subfamily in Vietnam. These species are characteristic for the prominent pair of spines on the abdominal tergites II-IV of males and long apically multidentate epiproct of females. The echinata species-group contains three exceptionally Bornean species, which are characterized by the long and apically pointed subgenital plate of females, which clearly projects beyond the epiproct, as well as the sub-basal lateral tooth of the anal segment of males. The muelleri species-group is sister to the remainder two species-groups.        Heteropteryx Gray, 1853 is a monotypical genus and only contains the type-species H. dilatata (Parkinson, 1798), which is found throughout Peninsular Malaysia, Thailand, Sumatra and Northeastern Borneo. This genus differs from Haaniella by the strongly conically elevated head, which posteriorly projects over the anterior margin of the pronotum, females being bright green or yellow in colour with plain and translucent pink alae and having distinct spines on the abdominal tergites, and males having a strongly shortened mesothorax and dull pink alae.        Lectotypes are designated for Haaniella parva Günther, 1944, Heteropteryx echinata Redtenbacher, 1906, Heteropteryx saussurei Redtenbacher, 1906 and Heteropteryx scabra Redtenbacher, 1906 to guarantee stability of these names.        Information on the habitats, host-plants, biology, life cycle, parasitism and captive breeding of the species of Heteropteryginae is presented and a list summarising all taxonomic changes presented herein.

GG genotype of cyclin D1 G870A polymorphism is associated with increased risk and advanced colorectal cancer in patients in Singapore.

Recent studies have implicated cyclin D1 G870A single-nucleotide polymorphism (SNP) in susceptibility to and early onset of colorectal cancers (CRC). We investigated the role of cyclin D1 G870A SNP in Singapore CRC patients without dominant family history by genotyping 254 patients and 101 controls. The risk of cancer for AA individuals was less than half that of GG individuals (odds ratio (OR) 0.41; 95% confidence interval (CI) 0.18-0.96). Furthermore, AA and AG patients whose tumours were Dukes C and D (OR 0.38; 95% CI 0.17-0.83), poorly differentiated (OR 0.28; 95% CI 0.09-0.84) and left-sided (OR 0.45; 95% CI 0.21-0.98) were associated with significantly lower risk than GG patients. Young (aged 50 years or less) GG patients had a 5-year lower mean age at onset than AA/AG patients (P=0.02). Young male GG patients had worse disease-specific survival than AA/AG patients (P=0.002). Thus, contrary to Caucasians, the GG (rather than AA) genotype is associated with increased susceptibility and advanced CRC in Singapore patients, suggesting a more complex relationship between the SNP and CRC risk, possibly modulated by population differences.

Surgical results of total mesorectal excision for rectal cancer in a specialised colorectal unit.

Our aim was to review the results of total mesorectal excision (TME) in a specialised colorectal unit. Perioperative and follow-up data were prospectively collected in a computerised database. A review of all the records was made. The morbidity rate was about 14%, and was higher in patients with coloplasty due to a higher anastomotic leak rate. The local recurrence rate was 2%, the distant metastasis rate was 11%, and both local and distant metastasis occurred in 4%. About 95% of recurrence occurred within 3 years. There was better bowel function in patients with a colonic J-pouch in the first 2 years after surgery, but the advantage disappeared thereafter. There were no differences in function between descending and sigmoid colonic J-pouches. TME in a specialised colorectal unit has low morbidity and mortality. Our procedure of choice is that of a sigmoid colon J-pouch anal anastomosis.

Unresectable desmoid tumours causing obstructive uropathy in familial adenomatous polyposis.

Desmoid tumour-related ureteral obstruction in familial adenomatous polyposis presents difficult management problems. Its role in altering prognosis for the worse in young patients has been neglected. Two patients are reported and 14 cases in the literature reviewed. Both our patients developed intra-abdominal desmoid tumours following proctocolectomies with pouch reconstruction (performed 0.7 and 2.5 years earlier). Despite therapy with sulindac and tamoxifen, both suffered progressive ureteral obstruction that required initial percutaneous drainage. Ureteral stenting was effective and safe in both patients (10 and 18 months' follow-up, respectively), but the long-term outcome awaits assessment. The optimal regimen of adjuvant medical therapy is uncertain. Successful renal autotransplantation and combination chemotherapy have been tried after failure of conventional therapy.

Intestinal type gastric adenocarcinoma with unusual synchronous metastases to the colorectum and bladder.

A 75-year-old male presented with difficult defecation and increasing urinary frequency over a few months. He had a significant history of previous partial gastrectomy for gastric carcinoma 20 years prior. Computed tomography of the abdomen and pelvis showed extensive lymphadenopathy, a gastric mass and rectal as well as bladder wall thickening with bilateral ureterohydronephrosis. Normal looking serosal surfaces of the bladder and bowel were seen on laparoscopy and a defunctioning ileostomy was created. Gastroscopy revealed a malignant mass while cystoscopy and sigmoidscopy found extensive tumour growth lining the mucosal surfaces. Biopsies from all sites were compatible with intestinal type adenocarcinoma of gastric origin with few signet ring cells. Metabolic response to palliative chemotherapy was good and the patient's symptoms have improved on follow-up four months post ileostomy. We discuss the immunohistochemical profile of the tumour and review the literature.

Differential cytostatic effect of sodium salicylate in human colorectal cancers using an individualized histoculture system.

PURPOSE: Tumor metastasis is the major cause of colorectal cancer (CRC) mortality. Nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin have been shown to have an antineoplastic effect in CRC cell lines. Different patients, however, exhibit different chemosensitivity. In this study, we assessed the chemotherapeutic potential of sodium salicylate, an aspirin metabolite, by measuring its cytostatic effect in an individualized three-dimensional histoculture system. METHODS: Histocultured cancer tissues were treated with sodium salicylate at concentrations from 1 to 10 m M for 24 or 48 h. Inhibition of DNA synthesis was measured in terms of inhibition of bromodeoxyuridine (BrdU) incorporation. RESULTS: The concentration response of individual cancer tissues could be categorized into four groups ranging from the most to the least sensitive to sodium salicylate. Of 20 cancer tissues, 12 (60%) showed a concentration-effect relationship with sodium salicylate in the clinically relevant concentration range (IC50 1.2+/-0.4 to 3.8+/-0.5 m M). Doubling the exposure time decreased the IC50 in four specimens, suggesting that a similar inhibition might be achieved with a lower concentration over an extended time. None of the right-sided cancers was sensitive to sodium salicylate ( P=0.002). CONCLUSIONS: Sodium salicylate had a cytostatic effect on the majority of histocultured CRC tissues. The varying chemosensitivity of the cancers possibly reflected underlying differences, for example in relation to cancer site, thus emphasizing further the usefulness of this clinically relevant system in tailoring chemotherapy to the individual patient.

Primary omental gastrointestinal stromal tumour (GIST) presenting with a large abdominal mass and spontaneous haemoperitoneum.

A 60-year-old Indonesian woman presented with a 9-day history of increasing abdominal distension, pain and tiredness. Physical examination revealed significant pallor with a palpable mass in the abdomen. CT of the abdomen reported a 22 cm complex mass in the peritoneal cavity with free intra-abdominal fluid. Laboratory results showed anaemia with a raised serum CA 125 level. At laparotomy a large haemorrhagic tumour with blood filled cystic cavities was found attached to both greater omentum and the transverse mesocolon with 2.2 L of blood in the peritoneal cavity. There was no invasion of any part of the stomach or intestines and there were no metastases seen. Histopathology of the resected specimen was consistent with that of a gastrointestinal stromal tumour arising from the omentum. Immunohistochemical studies revealed the tumour to be strongly positive for discovered on GIST-1 (DOG1) but negative for both CD117 and CD34. Platelet-derived growth factor receptor α (PDGFRA) exon 18 mutation D842V was detected.

Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms.

AIM: To investigate the effect of reducing dietary fiber on patients with idiopathic constipation. METHODS: Sixty-three cases of idiopathic constipation presenting between May 2008 and May 2010 were enrolled into the study after colonoscopy excluded an organic cause of the constipation. Patients with previous colon surgery or a medical cause of their constipation were excluded. All patients were given an explanation on the role of fiber in the gastrointestinal tract. They were then asked to go on a no fiber diet for 2 wk. Thereafter, they were asked to reduce the amount of dietary fiber intake to a level that they found acceptable. Dietary fiber intake, symptoms of constipation, difficulty in evacuation of stools, anal bleeding, abdominal bloating or abdominal pain were recorded at 1 and 6 mo. RESULTS: The median age of the patients (16 male, 47 female) was 47 years (range, 20-80 years). At 6 mo, 41 patients remained on a no fiber diet, 16 on a reduced fiber diet, and 6 resumed their high fiber diet for religious or personal reasons. Patients who stopped or reduced dietary fiber had significant improvement in their symptoms while those who continued on a high fiber diet had no change. Of those who stopped fiber completely, the bowel frequency increased from one motion in 3.75 d (± 1.59 d) to one motion in 1.0 d (± 0.0 d) (P < 0.001); those with reduced fiber intake had increased bowel frequency from a mean of one motion per 4.19 d (± 2.09 d) to one motion per 1.9 d (± 1.21 d) on a reduced fiber diet (P < 0.001); those who remained on a high fiber diet continued to have a mean of one motion per 6.83 d (± 1.03 d) before and after consultation. For no fiber, reduced fiber and high fiber groups, respectively, symptoms of bloating were present in 0%, 31.3% and 100% (P < 0.001) and straining to pass stools occurred in 0%, 43.8% and 100% (P < 0.001). CONCLUSION: Idiopathic constipation and its associated symptoms can be effectively reduced by stopping or even lowering the intake of dietary fiber.

Innovations in chronic anal fissure treatment: A systematic review.

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.

Outcomes for abdominoperineal resections are not worse than those of anterior resections.

PURPOSE: Local recurrence and cure rates following abdominoperineal resections have been reported to be much worse than sphincter-preserving anterior resections. We compared the oncologic outcomes of patients treated by abdominoperineal resections with those following sphincter-preserving anterior resections. METHODS: The medical records of patients who underwent radical rectal resection for rectal carcinoma at the Colorectal Surgery Department, Singapore General Hospital, during the period from April 1989 to April 2002 were reviewed. A total of 791 cases were studied. Operative procedures were classified as either abdominoperineal resections or anterior resections with either straight or pouch anastomosis. Total mesorectal excision was routinely performed for carcinomas of the lower middle and lower third of the rectum. Sentinel events, including local and systemic recurrences or morbidity and mortality, were tracked prospectively. RESULTS: There were a total of 93 abdominoperineal resections (12.1 percent), 547 anterior resections with straight anastomoses (71 percent), and 130 anterior resections with pouch anastomoses (16.9 percent). Postoperative mortality was 2.6 percent and postoperative morbidity was 13.6 percent with an overall anastomotic leakage rate of 2.5 percent. The cumulative five-year local recurrence rate was 5.4 percent for abdominoperineal resections, 3.6 percent for anterior resections with straight anastomoses, and 3.8 percent for anterior resections with pouch anastomoses (P = 0.73 by log-rank test). The median time to local recurrence also did not differ significantly between the different procedures (abdominoperineal resections, 17 months, anterior resections with straight anastomoses, 18 months, anterior resections with pouch anastomoses, 13 months). Independent predictors for local recurrence included advanced tumor stage, tumor depth, and poorly differentiated tumors. The five-year cancer-specific survival was 70 percent. The type of anastomosis did not influence disease-free survival with median disease-free survival for patients who underwent abdominoperineal resections being 100 months, survival of anterior resections with straight anastomoses being 135 months, and survival of anterior resections with pouch anastomoses being 121 months (P = 0.33 by log-rank test). The independent factors for poor survival were age greater than 65 years, advanced tumor stage, tumor depth, and poorly differentiated tumors. CONCLUSION: Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections.

Total mesorectal excision: the unrecognized pelvic plane.

Total mesorectal excision for low rectal cancers has been shown to reduce local recurrence rate after curative operation to <5 percent. The lack of anatomic appreciation of the mesorectum is an important cause of inter-surgeon variability in the outcome of rectal cancer surgery. Surgical illustrations depicting the mesorectal anatomy, however, are less than accurate. Basic surgical concepts must be illustrated correctly to be learned correctly. True-to-life illustration is the only way the learner can appreciate the actual situation and improve his/her surgical results. We describe the mesorectal anatomy with correlation to computerized tomography scans of the in vivo rectum to further illustrate the technique of total mesorectal excision in rectal cancer surgery.