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General Surgery
Perspective on Rectal Cancer (B)
Built from Maingot's Abdominal Operations
What’s inside
10 sections · 83 slides
Overview
- Scope of this commentary
- Points of agreement and points of challenge
Anatomic landmarks
Where you measure a rectal tumour from decides how it is treated
- Purpose of measuring tumour level
- The three landmarks in use
- Anal canal, sphincters and the dentate line
- The dentate line as a tissue boundary
- Effect of body habitus on measured tumour level
- The 5 cm lesion in two body types
- Variability of the anorectal ring
- Digital rectal examination of a low rectal tumour
- Consequences of inconsistent landmarks
- Anal canal anatomy and the muscles of continence
Preoperative assessment
Baseline imaging, and where a PET scan earns its cost
- Baseline imaging before rectal cancer surgery
- Selective use of PET scanning
- Whole-body PET and CT display
- Selective PET versus a repeat CT at three months
TNM staging
How the seventh edition regrouped stages II and III
- The three questions behind a stage
- The seventh edition and the Hindgut Taskforce
- Stage groupings from 0 to IV
- Reading the stage groupings
- Traditional subdivisions of stages II and III
- Data behind the seventh-edition changes
- Reclassification of T4b N0 tumours
- Tumours upgraded to stage IIIB
- Tumours reclassified as stage IIIC
- Clinical value of the reclassifications
Perioperative management
Where habit still outruns evidence
- Evidence and practice in perioperative care
- Oral mechanical bowel preparation
- Positions on routine bowel preparation
- 99%
- Interpreting the 2003 survey
- Proposed mechanism of harm from bowel preparation
- Reported complications of bowel preparation
- Remaining indications for bowel preparation
- Alternative practices at other centres
- The 2009 SSAT debate
- Determinants of wound infection
- Surgical Care Improvement Project measures
- Antibiotic timing and duration
- Single-dose ertapenem in teaching hospitals
- Urinary catheter removal in colorectal surgery
Local excision
Removing the tumour alone, and who can safely be offered it
- What local excision means
- Evidence base for transanal excision
- Selection criteria for T1 tumours
- Differentiation of colorectal adenocarcinoma
- The unresolved question of T2 tumours
- Benefits and the challenge to them
- Limits of current selection criteria
- Questions that markers alone will not settle
- Influence of surgical technique and volume
- The transcoccygeal approach
- Alternatives to the transcoccygeal approach
Quality of life
The endpoint that shapes four separate treatment decisions
- Quality of life as an endpoint
- Decisions shaped by quality of life
- Lateral pelvic lymph node dissection
- Indications for pelvic radiation
- Low anterior resection syndrome
- Colonic J-pouch: benefits and limits
- Choosing the bowel segment for a pouch
- Palliation with established distant disease
- Sequencing treatment for an asymptomatic primary
- Variations on the resection plan
- Local invasion and pain control
- Surgery for locally advanced and recurrent disease
- Stenting versus faecal diversion
- Permanent colostomy after resection for rectal cancer
Operative technique
Total mesorectal excision and one surgeon's standing routine
- Total mesorectal excision
- Pathologic assessment of the specimen
- Preoperative routine in the author's practice
- Thromboprophylaxis, haemostasis and drains
Postoperative care
Feeding patients earlier than tradition allowed
- Early refeeding after bowel surgery
- Evidence for early enteral feeding
- 80-90%
- A patient-controlled postoperative diet
- Foods encouraged and avoided
Summary
What to carry away from this commentary
- Key points on landmarks and staging
- Key points on perioperative practice
- Key points on excision, quality of life and recovery
- References
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition