Marilyne M. Lange

Level of arterial ligation in rectal cancer surgery: Low tie preferred over high tie. A review

Consensus does not exist on the level of arterial ligation in rectal cancer surgery. From oncologic considerations, many surgeons apply high tie arterial ligation (level of inferior mesenteric artery). Other strategies include ligation at the level of the superior rectal artery, just caudally to the origin of the left colic artery (low tie), and ligation at a level without any intraoperative definition of the inferior mesenteric or superior rectal arteries.Publications concerning the level of ligation in rectal cancer surgery were systematically reviewed. Twenty-three articles that evaluated oncologic outcome (n = 14), anastomotic circulation (n = 5), autonomous innervation (n = 5), and tension on the anastomosis/anastomotic leakage (n = 2) matched our selection criteria and were systematically reviewed. There is insufficient evidence to support high tie as the technique of choice. Furthermore, high tie has been proven to decrease perfusion and innervation of the proximal limb. It is concluded that neither the high tie strategy nor the low tie strategy is evidence based and that low tie is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. As a consequence, in rectal cancer surgery low tie should be the preferred method.

Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial

PURPOSE Total mesorectal excision (TME) for rectal cancer may result in anorectal and urogenital dysfunction. We aimed to study possible nerve disruption during TME and its consequences for functional outcome. Because the levator ani muscle plays an important role in both urinary and fecal continence, an explanation could be peroperative damage of the nerve supply to the levator ani muscle. METHODS TME was performed on cadaver pelves. Subsequently, the anatomy of the pelvic floor innervation and its relation to the pelvic autonomic innervation and the mesorectum were studied. Additionally, data from the Dutch TME trial were analyzed to relate anorectal and urinary dysfunction to possible nerve damage during TME procedure. RESULTS Cadaver TME surgery demonstrated that, especially in low tumors, the pelvic floor innervation can be damaged. Furthermore, the origin of the levator ani nerve was located in close proximity of the origin of the pelvic splanchnic nerves. Analysis of the TME trial data showed that newly developed urinary and fecal incontinence was present in 33.7% and 38.8% of patients, respectively. Both types of incontinence were significantly associated with each other (P = .027). Low anastomosis was significantly associated with urinary incontinence (P = .049). One third of the patients with newly developed urinary and fecal incontinence also reported difficulty in bladder emptying, for which excessive perioperative blood loss was a significant risk factor. CONCLUSION Perioperative damage to the pelvic floor innervation could contribute to fecal and urinary incontinence after TME, especially in case of a low anastomosis or damage to the pelvic splanchnic nerves.

Urinary and sexual dysfunction after rectal cancer treatment

In light of the improving prognosis for patients with rectal cancer, the quality of functional outcome has become increasingly important. Despite the good functional results achieved by expert surgeons, large multicenter studies show that urogenital dysfunction remains a common problem after rectal cancer treatment. More than half of patients experience a deterioration in sexual function, consisting of ejaculatory problems and impotence in men and vaginal dryness and dyspareunia in women. Urinary dysfunction occurs in one-third of patients treated for rectal cancer. Surgical nerve damage is the main cause of urinary dysfunction. Radiotherapy seems to have a role in the development of sexual dysfunction, without affecting urinary function. Pelvic autonomic nerves are especially at risk in cases of low rectal cancer and during abdominoperineal resection. Data concerning nerve damage during laparoscopic surgery for resection of rectal cancer are awaited. Structured education of surgeons with regard to pelvic neuroanatomy, and systematic registration of identified nerves, could well be the key to improving functional outcome for these patients. Meanwhile, patients should be informed of all associated risks before their operation, and their functional status should be evaluated before and after surgery.

Faecal and urinary incontinence after multimodality treatment of rectal cancer.

Marilyne Lange and Cornelis van de Velde discuss the differential diagnosis and management of incontinence after rectal cancer treatment.

Driving Surgical Quality Using Operative Video.

Recent evidence suggests surgical quality may be demonstrated and evaluated using video capture during surgery. Operative video documentation may also aid in quality improvement initiatives. We discuss how operative video has the potential to help improve patient outcomes and increase professional accountability, patient safety, and surgical quality.

Imaging for Quality Control: Comparison of Systematic Video Recording to the Operative Note in Colorectal Cancer Surgery. A Pilot Study

Background Oncological and functional results after colorectal cancer surgery vary considerably between hospitals and surgeons. At present, the only source of technical information about the surgical procedure is the operative note, which is subjective and omits critical information. This study aimed to evaluate the feasibility of operative video recording in demonstrating both objective information concerning the surgical procedure and surgical quality, as using a systematic approach might improve surgical performance.

The role of radiotherapy in the causation of poor function after rectal cancer treatment

Dear Sir, We read with interest the article by Saeed et al. [1]. on the incidence of hernia at the site of temporary loop ileostomy closure. Although at 1-year follow-up they did not visualize any case of a hernial sac, 37% (16/43) had either muscle atrophy or a defect. It should be noted that the postoperative surveillance computed tomography (CT) scans used were not optimized to detect hernia formation, in contrast to some previously published studies [2]. No patient was reported as requiring surgical repair of a hernia at the stoma closure site. We have published a systematic review on this topic pooling data from 2729 stoma closures. Approximately one in three sites was found to develop an incisional hernia on subsequent follow-up [3]. Around half the hernias detected required repair. We have also previously published a very similar study to that of Saeed et al., analysing postoperative surveillance imaging from 59 stoma closures [4]. We again found that the rate of herniation was one in three, and that one in five patients with a hernia required surgical repair. These are patients who have often undergone two or three major colorectal operations. They may not want further surgery, being willing to live with a symptomatic or disfiguring hernia rather than undergo another operation. As follow-up lengthens, the small defects detected on CT may well become larger and symptomatic. Follow-up in the study by Saeed et al. appears to have been performed by a stomatherapist. There is a paucity of data on quality of life related to herniation at the stoma closure site. That no repairs were required is a reflection of the small sample size and goes against the published trend. Saeed et al. conclude by stating that true herniation is uncommon and that prophylactic reinforcement during closure of the stoma site is unnecessary. We do not believe that their sample size and study design are sufficiently robust to support this statement. In the absence of prospective studies, evaluating such conclusions may deny patients potentially significant improvement in quality of life. We have planned a randomized controlled trial of reinforcement of stoma site closure to answer this very question. Quality of life and cost analysis are key secondary endpoints. We would be delighted if the authors would join this multicentre study to help answer the question. A. Bhangu, T. Pinkney, D. Nepogodiev, K. Futaba and D. Morton West Midlands Research Collaborative, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK E-mail: aneelbhangu@doctors.org.uk

What Is Cancer of the Rectum

Rectal cancer constitutes one-third of all colorectal cancers, representing the cancer with the second highest incidence and the second cause of cancer death in the western society [1, 2]. An estimated 100,000 new cases of rectal cancer are diagnosed each year in Europe. The incidence is increasing, mainly due to earlier detection and increasing age of the population, as the highest incidence of rectal cancer is found in the sixth and seventh decades. High incidence rates are found especially in western world populations, i.e. Western Europe, North America and Australia. This can probably be explained by a combination of factors, including dietary patterns with high amounts of red meat, obesity and smoking [3]. The United States is the only country with significantly decreasing incidence rates in both males and females in the most recent time period, which largely reflects detection and removal of precancerous lesions through colorectal cancer screening [4]. Next to dietary and life-style factors, risk factors for rectal cancer include inflammatory bowel disease and primary sclerosing cholangitis. Also genetic predisposition plays a role; however, rectal cancer most commonly occurs sporadically and is inherited in only 5% of the cases. Five-year survival rate of rectal cancer is about 60% and depends to a large extent on disease stage at diagnosis [5].

What Do We Consider Cancer of the Rectum

Rectal cancer constitutes one third of all colorectal cancers, representing the cancer with the second highest incidence and the second cause of cancer death in the western society [1, 2]. An estimated 100,000 new cases of rectal cancer are diagnosed each year in Europe. The incidence is increasing, mainly due to earlier detection and increasing age of the population, as the highest incidence of rectal cancer is found in the sixth and seventh decades. High incidence rates are found especially in western world populations, i.e. Western Europe, North America and Australia. This can probably be explained by a combination of factors, including dietary patterns with high amounts of red meat, obesity and smoking [3]. The United States is the only country with significantly decreasing incidence rates in both males and females in the most recent time period, which largely reflects detection and removal of precancerous lesions through colorectal cancer screening [4]. Next to dietary and lifestyle factors, risk factors for rectal cancer include inflammatory bowel disease and primary sclerosing cholangitis. Also, genetic predisposition plays a role; however, rectal cancer most commonly occurs sporadically and is inherited in only 5% of the cases. Five-year survival rate of rectal cancer is about 60% and depends to a large extent on disease stage at diagnosis [5].

Ligation of the descending branch of the left colic artery to increase colon length in low-tie ligation.

To the Editor—The length of the descending colon limb needed for a tension-free anastomosis is an important aspect of the ongoing debate on the appropriate level of vascular ligation in colorectal cancer surgery. I read with great interest the article by Bonnet et al, in which the authors describe their anatomic experimental study on the impact of the level of vascular ligation on the gain in descending colon length after sigmoidectomy and splenic flexure mobilization. They used 30 fresh cadavers free of formalin fixation to compare 2 ligation techniques: 1) high-tie, defined as division of the inferior mesenteric artery 1 cm distally to its origin at the aorta; 2) low-tie, defined as division of the upper rectal artery 1 cm distally to the origin of the left colic artery. The authors conclude that the gain in colonic length is 10 cm greater with high-tie than with low-tie ligation, resulting in a 100% feasibility rate of anastomosis with the high-tie technique compared to a maximum of 87% feasibility after low-tie ligation. My question is what the feasibility rate would be in low-tie ligation if the descending branch of the left colic artery were transected, as this was shown to be an important limiting factor in a previous study. Transection of the descending branch of the left colic artery in low-tie ligation might offer a good alternative to high-tie ligation. It may increase the feasibility rate of the low-tie technique while offering an alternative vascularization by means of the ascending branch of the left colic artery in patients with an incomplete arch of Riolan (marginal artery of Drummond), or in patients with compromised vascularization and those who are at risk of superior mesenteric artery stenosis.