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Mesorectum PDF
Mesorectum PDF
Mesorectum PDF
Second part
Abstract
Perirectal fat separated by the rectal facia - the so-called mesorectum - is the first area of local rectal cancer
dissemination. Thus, its removal along with the rectum affected by the tumour is essential for preventing local
tumour recurrence. The mesorectum, as an anatomical and surgical concept, reconciles two major objectives of rectal
cancer surgery: the radical surgical act and reduced postoperative urinary and genital complications. Besides these
main targets, the concept of total mesorectal excision is useful in determining an avascular area suitable for rectal
dissection and in setting a new parameter for the evaluation of radical surgery (circumferential resection edge).
Understanding the local anatomy and especially the nerves and vascular relations of this anatomical structure is
essential for optimum rectal cancer surgery. Key words: mezorect; cancer rectal; excizia totala a mezorectului.
Rezumat
Adipozitatea perirectala delimitat de fascia proprie a rectului - aa-numitul mezorect - este zona initiala de
diseminare a cancerului de rect, iar indepartarea acesteia in bloc cu rectul tumoral este o conditie esentiala a
prevenirii recidivei locale. Mezorectul ca sj concept anatomo-chirurgical reconciliaza doua obiective ale operatiei
pentru cancerul de rect: radicalitatea actului chirurgical si limitarea sechelelor uro-genitale ale acestuia. In afara
acestor obiectiv principale, conceptul de excizie totala a mezorectului este util pentru defmirea unui plan avascular
pentru disectie i definirea unui parametral pentru evaluarea radicalitatii actului chirurgical (marginea
circumferentiala de rezectie). Cunoaterea anatomiei locale i in special a raporturilor nervoase i vasculare ale
acestei structuri anatomice este esentiala pentru chirurgia optima a cancerului de rect. Cuvinte cheie: mesorectum;
rectal cancer; total mesorectal excision.
Introduction
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Dukes CE - The classification of cancer of the rectum , Journal of Pathology and Bacteriology 1932, 35: 323-331 - cited by Astler and Coller (5)
Mesorectum
Rectum - elements of descriptive anatomy
Superior (proximal) limit of the rectum
(rectum-sigmoid joint) is considered by the anatomists
to lie at the level of S3 vertebrae. Surgeons consider this
limit to lie at the level of the sacral promontory (38-39).
More important than these topography criteria are the
descriptive ones that consider the beginning of the
rectum in the region where the muscular longitudinal
bands (taeniae) of the colon (longitudinal muscular
layer becomes wider and inverts the rectum completely),
the saculation of the colon (taenia coli), the pelvic
mesocolon {mesocolon sigmoideum) and the
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Rectal arteries
Arterial blood flow for the rectum (fig. 2) is
provided by the superior haemorrhoidal artery and also
by minor arterial sources: medium sacral artery,
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Perirectal fasciae
The parietal fascia of the pelvis covers the
walls and the pelvic diaphragm. It stretches also over
the pelvic organs, forming the visceral fasciae. Around
the rectum it forms the own rectal sheath, or perirectal
fascia. It was first mentioned by Toma Ionescu in the
anatomy treatise by Poirier and Charpy (17, 57). The
Rectosacral fascia is called by some authors the Waldeyer fascia; others use the same name for the presacral fascia. In fact, W. Waldeyer
described the presacral fascia, but not its recto-sacral extension.
Ovidiu Fabian
28
Richardson AC - The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocel repair, Clin Obstet Gynecol 1993,
36: 976-983 - cited by Lindsey (58) and van Ophoven (59).
References
1.
29
30
202
30. Law WL, Chu KW - Anterior resection for rectal
cancer with mesorectal excision, a prospective
evaluation of 622 patients, Ann Surg 2004, 240 (2):
260-268
31. Carlsen, E Schlichting, Guldvog, Johnson, Heald Effect of the introduction of total mesorectal
excision for the treatment of rectal cancer, Br J
Surg 1998, 85 (4): 526-529.
32. Wibe A, Mfoller B, Norstein J, Carlsen E, Wiig JN,
Heald RJ, Langmark F, Myrvold HE, Soreide O - A
national strategic change in treatment policy for
rectal cancer - implementation of total mesorectal
excision as routine treatment in Norway. A
National audit, Dis Colon Rectum 2002, 45 (7):
857-866
33. Wibe A, Eriksen MT, Syse A, Myrvold HE - Total
mesorectal excision for rectal cancer - what can be
achieved by a national audit?, Colorect Dis 2003, 5
(5): 471-477
34. Goldberg S, Klas JV - Total mesorectal excision in
the treatment of rectal cancer: a view from the
USA, Semin Surg Oncol 1998, 15(2): 87-90
35. Wiig JN, Carlsen E, Soreide O - Mesorectal
excision for rectal cancer: A view from Europe,
Semin Surg Oncol 1998, 15 (2): 78-86
36. Bernardshawa SV, Ovrebob K, Eidec GE,
Skarsteinb A, Rtfkked O - Treatment of rectal
cancer: reduction of local recurrence after the
introduction of TME - Experience from one
university hospital, Dig Surg 2006, (1-2): 51-59
37. Soreide O, Norstein J - Local recurrence after
operative treatment of rectal carcinoma: a strategy
for change, J Am Col Surg 1997, 184: 84-92
38. Marcio J, Jorge N, Habr-Gama A - Anatomy and
embryology of the colon, rectum, and anus, in
Wolff BG, Fleshman JW, Beck DE, Pemberton JH,
Wexner SD - The ASCRS textbook of colon and
rectal surgery, Springer, New-York, 2007 - cpt. 1
39. Salerno G, Sinnatamby C, Branagan G, Daniels IR,
Heald RJ, Moran BJ - Defining the rectum:
surgically, radiologically and anatomically,
Colorect Dis 2006, 8 (Suppl. 3), 5-9
40. Skandalakis JE - Surgical anatomy: the
embryologic and anatomic basis of modern surgery,
McGraw-Hill Professional Publishing, 2004, cpt. 18
- Large intestine and anorectum
41. Mandache F, ChiricuJ)a I - Chirurgia rectului, Ed.
Medicala, Bucureti 1957
42. Sato T, Sato K - The vascular and neuronal
composition of the lateral ligament of the rectum
and the rectosacral fascia, Surg Radiol Anat 1991,
13: 17-22
43. Jones OM, Smeulers N, Wiseman O, Miller R Lateral ligaments of the rectum: an anatomical
study, Br J Surg 1999, 86: 487-489
Ovidiu Fabian
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32
86.
87.
88.
89.
90.
91.
92.
93.
94.
Abstract
Perirectal fat separated by the rectal facia - the so-called mesorectum - is the first area of local rectal cancer
dissemination. Thus, its removal along with the rectum affected by the tumour is essential for preventing local
tumour recurrence. The mesorectum, as an anatomical and surgical concept, reconciles two major objectives of rectal
cancer surgery: the radical surgical act and reduced postoperative urinary and genital complications. Besides these
main targets, the concept of total mesorectal excision is useful in determining an avascular area suitable for rectal
dissection and in setting a new parameter for the evaluation of radical surgery (circumferential resection edge).
Understanding the local anatomy and especially the nerves and vascular relations of this anatomical structure is
essential for optimum rectal cancer surgery. Key words: mesorectum; rectal cancer; total mesorectal excision.
Rezumat
Adipozitatea perirectala delimitat de fascia proprie a rectului aa-numitul mezorect - este zona initiala de
diseminare a cancerului de rect, iar indepartarea acesteia in bloc cu rectul tumoral este o conditie esentiala a
prevenirii recidivei locale. Mezorectul ca si concept anatomo-chirurgical reconciliaza doua obiective ale operatiei
pentru cancerul de rect: radicalitatea actului chirurgical si limitarea sechelelor uro-genitale ale acestuia. In afara
acestor obiectiv principale, conceptul de excizie totala a mezorectului este util pentru definirea unui plan avascular
pentru disectie i definirea unui parametru pentru evaluarea radicalitatii actului chirurgical (marginea
circumferentiala de rezectie). Cunoasterea anatomiei locale si in special a raporturilor nervoase i vasculare ale
acestei structuri anatomice este esentiala pentru chirurgia optima a cancerului de rect. Cuvinte cheie: mezorect;
cancer rectal; excizia totala a mezorectului
Embryology
52
Ovidiu Fabian
Fig.7. The development of the rectum, anal canal and genito-urinary organs,
a - diagram of the digestive tract - by Sadler (62).
Fig.7. The development of the rectum, anal canal and genito-urinary organs, b development of the rectum, anal canal and genito-urinary organs - by Sadler (62).
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Mesorectum
The mesorectum is not a real mesentery and
that is why the term must be accepted as a linguistic
convention. The term mesorectum defines the adipose
tissue that surrounds the rectum, surrounded by its own
fascia and is the first field of rectal cancer spreading
(64)-fig. 8.
Fig.8. Mesorectum b - transversal section - by Heald (2) representation of the histology sample obtained by Patrick Walsh.
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and the iliac vessels. From the rectal coats, only the
mucosa (shown as a fine line with low signal), the
submucosa (with high intensity signal) and the muscular
coat as a 2 layer structure (internal layer - regular corresponding to the circular muscles; external layer irregular - corresponding to the longitudinal muscles)
Fig.9. Aspect of the mesorectum in an MRI image (sagittal section) - by Salerno (39).
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Fig. 10. Rectal tumour dissemination in the mesorectum - continuous and discontinuous
- according to Quirke (10).
57
Fig.l 1. Preservation of the autonomic innervation during rectal resection with mesorectal
excision - by Yano and Moran (81)
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References
l.Sinnatamby CS - Anatomical aspects of total
mesorectal excision, The TME Workshop 2003,
Pelican Cancer Foundation, http://tycohealthece.com/files/d000 l/tylcxqto.pdf
2. Heald RJ - The 'Holy Plane' of rectal surgery, J R
Soc Med 1988, 81:503-508
3. Miles EW - A method of performing abdominoperineal excision for carcinoma of the rectum and
of the terminal portion of the pelvic colon, Lancet
1908, 2: 1812-1813, republicat in CA Cancer J Clin
1971;21:361-364
4. Yeatman TJ, Kirby IB - Sphincter-saving
procedures for distal carcinoma of the rectum, Ann
Surg 1988, 209: 1-18
5. Astler VB, Coller FA- The prognostic significance
of direct extension of carcinoma of the colon and
rectum, Ann Surg 1954, 139: 846-851
6. Galandiuk S, Chaturvedi K, Topor B - Rectal
cancer: a compartmental disease. The mesorectum
and mesorectal lymph nodes, in Biichler MW,
Heald RJ, Ulrich B, Weitz J- Rectal Cancer
Treatment, Springer-Verlag, Berlin-Heidelberg,
2005 (Recent results in cancer research 2005, 165:
21-29
7. Heald RJ, Husband EM, Ryall RDH - The
mesorectum in rectal cancer surgerythe clue to
pelvic recurrence?, Br J Surg, 1982 69: 613-616
8. Dixon CF - Surgical removal of lesions occur in the
sigmoid and rectosigmoid, Am J Surg 1939, 46: 1217
9. Fain N, Patin CS, Morgenstern L - Use of a
mechanical suturing apparatus in low colorectal
anastomosis, Arch Surg 1975, 110: 1079-1082
10. Quirke P, M. Dixon F, Durdey P, Williams NS Local recurrence of rectal adenocarcinoma due to
inadequate surgical resection. Histopathological
study of lateral tumor spread and surgical excision,
Lancet 1986, 8514:996-999
11. Fazio V, Fletcher J, Montague D - Prospective
study of the effect of resection of the rectum on
male sexual function, World J. Surg. 1980, 4: 149151
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25. Arbman G, Nilsson E, Hallbook O, Sjodahl R Local recurrence following total mesorectal
excision for rectal cancer, Br J Surg 1996, 83 (3):
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26. Arenas RB, Fichera A, Mhoon D, Michelassi F Total mezenteric excision in the surgical treatment
of rectal cancer, Arch Surg 1998, 133: 608-612
27. Leo E, Belli F, Andreola S, Gallino G, Bonfanti G,
Ferro F, Zingaro E, Sirizzotti G, Civelli E, Valvo F,
Gios M, Brunelli C - Total rectal resection and
complete mesorectum excision followed by
coloendoanal anastomosis as the optimal treatment
for low rectal cancer: The experience of the
National Cancer Institute of Milano, Ann Surg One,
7(2): 125-132
28. Ridgway PF, Darzi AW - The role of total
mesorectal excision in the management of rectal
cancer, Cancer Control 2003, 10 (3): 205-211
29. Del Rio C, Sanchez-Santos R, Oreja V, De Oca J,
Biondo S, Pares D, Osorio A, Marty-Rague J,
Jaurrieta E - Long-term urinary dysfunction after
rectal cancer surgery, Colorect Dis 2004, 6: 198202
30. Law WL, Chu KW - Anterior resection for rectal
cancer with mesorectal excision, a prospective
evaluation of 622 patients, Ann Surg 2004, 240 (2):
260-268
31. Carlsen, E Schlichting, Guldvog, Johnson, Heald Effect of the introduction of total mesorectal
excision for the treatment of rectal cancer, Br J Surg
1998, 85 (4): 526-529.
32. Wibe A, IVMler B, Norstein J, Carlsen E, Wiig JN,
Heald RJ, Langmark F, Myrvold HE, S0reide O - A
national strategic change in treatment policy for
rectal cancer - implementation of total mesorectal
excision as routine treatment in Norway. A National
audit, Dis Colon Rectum 2002, 45 (7): 857-866
33. Wibe A, Eriksen MT, Syse A, Myrvold HE - Total
mesorectal excision for rectal cancer - what can be
achieved by a national audit?, Colorect Dis 2003, 5
(5): 471-477
34. Goldberg S, Klas JV - Total mesorectal excision in
the treatment of rectal cancer: a view from the
USA, Semin Surg Oncol 1998, 15(2): 87-90
35. Wiig JN, Carlsen E, S0reide O - Mesorectal
excision for rectal cancer: A view from Europe,
Semin Surg Oncol 1998, 15 (2): 78-86
36. Bernardshawa SV, Ovrebob K, Eidec GE,
Skarsteinb A, Rakked O - Treatment of rectal
cancer: reduction of local recurrence after the
introduction of TME - Experience from one
university hospital, Dig Surg 2006, (1-2): 51-59
37. S0reide O, Norstein J - Local recurrence after
operative treatment of rectal carcinoma: a strategy
for change, J Am Col Surg 1997, 184: 84-92
Ovidiu Fabian
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Ovidiu Fabian