Y. SRINIVAS, A. RENWICK, P. MCARDLE and A. MACDONALD Department of Surgery, Monklands Hospital, Airdrie, U.K.
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A simple and safe method of mesorectal transection in stapled anastomoses for carcinoma of the upper third of rectum is described.
Keywords: mesorectum, rectal cancer
J.R.Coll.Surg.Edinb., 46, December 2001, 338-339
Figure 1: Guiding the staple gun between mesorectum and bowel with the help of the catheter
Figure 2: Firing the staple gun occludes the rectum below the tumour
While total mesorectal excision (TME) is the management of choice for carcinoma of the middle third of the rectum, upper third lesions are routinely treated by anterior resection with transection 5 cm below the lower border of the tumor. The traditional approach to mesorectal transection, which can result in failure to divide the mesorectum at 90o to the bowel, has led some to believe that TME should also be employed for upper third lesions.
Natural coning of the mesorectum and narrowing of the lumen make distal placement of a small stapling device (TA 30) straight forward. In contrast, the combination of a tumour, bulky mesorectum and narrow pelvis, can make accurate division of the mesorectal fat and subsequent placement of a staple gun difficult in the mid-rectum. A technique is described which uses a Jacques catheter to guide the staple gun into the correct anatomical plane.
The sigmoid colon and upper rectum are mobilized as for TME. At a point 5 cm below the lower border of the tumor, the mesorectum is opened laterally. Next, the plane between the mesorectum and the rectum is identified and a long artery forceps is passed through. A Jacques catheter (size 12) is brought back through the window created. (Figure 1) The tip of the lower lip of the staple gun (TA 55) is threaded into the lumen of the catheter. The catheter is then pulled slowly through, leading the staple gun. Firing the stapling device occludes the rectum below the tumor. The bowel is divided below the staple gun after rectal lavage with sterile water. (Figure 2) The mesorectum behind can now be seen easily and divided under direct vision in a plane away from the tumour, thus preventing a close shave of the mesorectum. (Figure 3). A purse-string suture can then be placed in the distal rectum in preparation for a stapled anastomosis. Alternatively, the staple gun can be lead through a second time and with downward angulation, a second firing can be performed, dividing the lower rectum above the staple gun. An end to end anastomosis can then be performed using the double staple technique.
Figure 3: The mesorectum behind can be seen easily and divided under direct vision
Low anterior resection remains a technical challenge because it involves bowel resection and anastomosis in the deep, limited pelvic space. Some modifications of the standard stapled anastomosis are needed to facilitate the procedure, making it safer, easier and more reliable. With this method using the catheter as a guide, the stapling gun can be guided atraumatically into place, at a low level, thus paving way for a good and sound anastomosis. We find this procedure useful in both the elective and emergency situation.
Correspondence: A. Macdonald, Monklands Hospital, Monkscourt Avenue, Airdrie ML6 OJS, Scotland, U.K. E-mail: publications@rcsed.ac.uk
Copyright date: 14th August 2001
Treatment and outcome of cystosarcoma phyllodes in Brunei: a 13-year experience
K.Y.Y KOK*, P.U. TELESINGHE# and S.K.S. YAPP*
*Department of Surgery and #Department of Pathology, Ripas Hospital, Bandar Seri Begawan, Brunei
J.R. Coll.Surg.Edinb. 46, August 2001, 198-201
Due to a production error the wrong abstract was published for this article. The abstract should have read as follows:
Cystosarcoma phyllodes is a rare tumour of the breast whose clinical behaviour does not correlate well with histological findings. The optimal treatment of this tumour remains controversial. A retrospective study on the treatment and outcome of women diagnosed with cystosarcoma phyllodes between 1986 and 1998 in Brunei was undertaken. Twenty-seven women were diagnosed over the 13-year study period. Follow-up was complete in 26 cases. The mean age at diagnosis was 35 years. There were 19 (73%) histologically benign lesions, 3 (12%) borderline lesions and 4 (15%) malignant lesions. The mean follow-up period was 37 months. Four patients (16%) had recurrences after surgery (1 benign, 1 borderline and 2 malignant lesions). Mean time to recurrence was 9 months. Breast-conserving surgery with adequate resection margin is advocated in benign and borderline lesions. For malignant lesions, simple mastectomy without routine axillary dissection is recommended. More research is required to determine the role of adjuvant chemotherapy and radiotherapy in the management of malignant cystosarcoma phyllodes.
Keywords: cystosarcoma phyllodes, histological categories, surgery, recurrence, adjuvant therapy