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For many years, poor vascularization of the short rectal stump has been considered the main cause of leakage. The purpose of this study was to evaluate the vascularization of the rectal stump after total mesorectal excision. We studied the iliac vascularization on 28 volunteers with healthy rectum to have an anatomic basis. Then, we studied the vascularization of the rectal stumps after total mesorectal excision by using angio computed tomography at seven and three months after operating on 22 patients; we validated this technique by studying the vascularization using angio computed tomography in 18 rectal specimens from cadavers. Both in healthy rectums and in rectal stumps after total mesorectal excision, there is good vascularization substained by middle and inferior rectal arteries. The former is more important and frequent as described in previous literature. The vascularization of the short rectal stump is generally well represented even after total mesorectal excision. [ABSTRACT FROM AUTHOR]

Objective The quality of surgical excision is held to be a major determinant of outcome following surgery for rectal cancer. Macroscopic examination of the excised mesorectum allows for reproducible assessment of the quality of surgery. We aimed to determine whether quality of excision undertaken by colorectal trainees under supervision was comparable with that performed by consultants, as measured using mesorectal grades. Method A total of 130 consecutive patients undergoing potentially curative resection for primary adenocarcinoma of the rectum in our centre from 2001 to 2003 were included in the study. The pathologists graded the excised mesorectum according to staged classification proposed by Quirke. The outcome (quality of mesorectal excision and secondary outcomes including local recurrence and overall recurrence) of operations performed by consultants was compared with that of trainees. Statistical significance was tested using Pearson χ2 test. Results Eighty-nine operations were performed by consultants and 41 by senior colorectal trainees with consultant supervision. Forty-four patients (49%) had good mesorectum when operated by consultants in comparison with 17 (41.5%) by the trainees. There was no statistically significant difference ( P = 0.717) between the two groups in terms of quality of mesorectum excised after potentially curative resection. Furthermore, there were seven local recurrences in patients operated by consultants (7.8%) when compared with four in the trainee group (9.5%) and once again there was no statistical significance between the two groups ( P = 0.719). Conclusion We conclude that the quality of rectal cancer excision, as defined by mesorectal grades, achieved by supervised colorectal trainees is comparable with that achieved by consultants. [ABSTRACT FROM AUTHOR]

Objective The presence of microscopic tumour cells within 1 mm of the circumferential surgical resection margin (CRM) is the endpoint most strongly associated with local recurrence in rectal cancer and doubles the risk of developing distant metastases. Reporting on the CRM can monitor surgical quality assurance and over the past two decades has driven advances in surgical technique with the increasing use of total mesorectal excision. The aim of this review was to use the evidence from both phase II and phase III randomized trials of preoperative radiotherapy and chemoradiation in rectal cancer, to assess how often CRM involvement is currently documented and examine its utility as an early predictor of both disease-free and overall survival. Method A literature search identified both randomized and nonrandomized trials of preoperative radiation therapy and chemoradiation therapy in rectal cancer since 1993. The aim was to find those studies, which documented the distance from the periphery of the tumour and the CRM. Small trials treating < 20 patients were excluded. Results One hundred and eighty-seven phase II and 28 phase III trials of preoperative radiotherapy or chemoradiation were identified. Most trials documented the degree of response but only 10 of 187 phase II/retrospective studies and four of 28 phase III trials presented data on the achievement of a negative CRM. Few defined this early pathological endpoint prospectively with accurate measurements. However, the majority of studies did use the definition of ≤ 1 mm as an involved CRM. Discussion Pathological parameters have been used as early endpoints to compare studies of preoperative radiotherapy or chemoradiation. It remains uncertain whether the degree of response to chemoradiation (e.g. complete pathological response, downsizing the primary tumour, sterilizing the regional nodes, tumour regression grades or residual cell density) or the achievement of a curative resection (uninvolved CRM) is the best early clinical endpoint. Retrospective studies in rectal cancer have confirmed a strong association between the presence of microscopic tumour cells within 1 mm of the CRM and increased risks of both local recurrence and distant metastases. However, as yet this early pathological endpoint lacks structured measurement and analysis techniques to control for intra- and inter-observer variation and has not been validated as a potential surrogate for local control and survival. Recommendations are made as to the most appropriate information, which should be documented in future trials. Conclusion The CRM status predicts outcome after surgery alone, preoperative radiotherapy and preoperative chemoradiation. Yet CRM status and its measurement has been poorly documented in the literature, and rarely as a prospective measure of outcome. The CRM should be measured and documented in all cases, using the definition of ≤ 1 mm to denote an involved CRM. This definition should also be incorporated into future rectal cancer studies with the use of a standardized proforma. [ABSTRACT FROM AUTHOR]

Objective Despite improvement in management of primary rectal cancer, 2.6–32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes. Method A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated. Results Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Conclusion Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential. [ABSTRACT FROM AUTHOR]

Objective Guidelines for the urgent referral of patients with suspected colorectal cancer were introduced in 2000. They aimed to facilitate the prompt diagnosis and treatment of patients with symptoms suggestive of malignant disease. Recent assessment of these guidelines has suggested that although they identify 9–14% of patients with colorectal cancer, they may be used inappropriately and may lead to delays in treatment for those patients with cancers whose symptoms do not fit the guidelines. We aimed to assess the effect of introducing a single pathway for all referrals irrespective of indicated urgency. Method All referral letters to a single consultant colorectal surgeon over a 6-month period were coded ‘urgent’ irrespective of the indicated urgency on the original referral letter. Data was collected prospectively on 47 patients diagnosed with colorectal cancer identified over the trial period. Patient demographics, the mode of presentation, urgency of referral and waiting times were documented. Results Following the introduction of the common urgent referral pathway, no patient waited longer than 62 days from referral to treatment or 31 days from the decision to treat to first treatment, thus meeting government targets introduced in 2005. Conclusion The introduction of the urgent referral guidelines has accelerated the referral pathway for patients with symptoms suggestive of colorectal cancer, although this is at the expense of the majority of patients who present via conventional pathways. The introduction of a common urgent pathway allows prompt diagnosis and treatment and is of particular benefit for the majority of patients not referred via the 2-week standard. Until a more accurate method of identifying the highest risk patients is implemented, we suggest that all patients are seen on an urgent basis. [ABSTRACT FROM AUTHOR]

Introduction It has generally been considered that open pelvic surgery is almost always easier in female subjects because of anatomical differences facilitating surgical access. In contrast, the male pelvis has been considered to be narrower and deeper. The objective of this study was to assess magnetic resonance imaging (MRI) pelvimetry in patients with rectal cancer in whom any difference in pelvimetry may potentially affect operative management. Male and female pelvic bony dimensions were compared. Method A cohort of 186 patients (112 males and 74 females) with rectal cancer who had been recruited prospectively to the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study (MERCURY Study) were assessed. Complete digital images were available on these patients. A comparison of the pelvic dimensions was made between the sexes using 16 dimensions measured on the MRI workstation using the mid-sagittal and axial images. Results There was no significant difference and considerable overlap between the sexes with respect to each of the 14 parameters measured from the preoperative sagittal MRI scan. However, there was a highly significant difference between the interspinous and intertuberous transverse diameter of the pelvis ( P < 0.0001). Conclusion Outcome after surgery may be influenced by the technical difficulty of the operation and this had been thought to be partly affected by the pelvic size. In this cohort of 186 patients, the only difference seen between the sexes, was in the transverse mid-inlet and pelvic outlet diameter. [ABSTRACT FROM AUTHOR]

The article focuses on the importance of the Holy Plane, an avascular interface between viscus and soma to the rectal surgery. It is said that the pursuit for Holy Plane in the hindgut will enable one to make every restorative rectal excision similar to slight modification at the lower end for the abdominoperineal case. In addition, the Holy Plane can be useful in non-malignant diseases which can be carried down to the intersphincteric groove.

The article discusses the anatomy and histology of the anal canal and its clinical relevance to anal cancers. The author highlights the histological and anatomical changes to the traditional terminology of the anal canal and describes the gross anatomy of the anal canal along with its associated blood supply, venous and lymphatic drainage, and nerve supply. The author believes that the terminology referred in the article could assist clinicians and health care providers to identify lesions more precisely through naked-eye observation.

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Objective: Patients with a history of colorectal cancer are considered at increased risk of second metachronous colorectal cancer (SM-CRC), for which they frequently receive intensive colonoscopic surveillance. In view of the ambiguous nature of the existing evidence and the growing interest in targeted surveillance, we sought to quantify long-term risk with particular reference to age at diagnosis. Method: The Surveillance Epidemiology and End Results database was used to estimate risk of SM-CRC after first incident colorectal cancer diagnosed between 1975 and 1999. We calculated time-dependent rates using Kaplan–Meier estimates and relative risk compared with the US general population. Results: From 311 689 eligible patients, there were 6387 SM-CRCs. At 15-years following initial diagnosis, the SM-CRC rate was 6.3% (95% CI, 6.1–6.5). For patients with synchronous primary cancers ( n = 9936, 3.2%), the 15-year SM-CRC rate increased to 10.5% (95% CI, 9.1–12.2). Younger age predicted for increased relative risks but absolute cumulative rates at 15 years were low (Table). Conclusion: The long-term cumulative risk of SM-CRCs after first colorectal cancer is low, even among younger age patients. These data do not support the routine use of high-frequency colonoscopy surveillance in patients with a history of colorectal cancer. [ABSTRACT FROM AUTHOR]