1
|
Wang J, Liu H, Li A, Jiang H, Pan Y, Chen X, Yin L, Lin M. A new membrane anatomy-oriented classification of radical surgery for rectal cancer. Gastroenterol Rep (Oxf) 2023; 11:goad069. [PMID: 38145104 PMCID: PMC10739184 DOI: 10.1093/gastro/goad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 12/26/2023] Open
Abstract
For patients with different clinical stages of rectal cancer, tailored surgery is urgently needed. Over the past 10 years, our team has conducted numerous anatomical studies and proposed the "four fasciae and three spaces" theory to guide rectal cancer surgery. Enlightened by the anatomical basis of the radical hysterectomy classification system of Querleu and Morrow, we proposed a new classification system of radical surgery for rectal cancer based on membrane anatomy. This system categorizes the surgery into four types (A-D) and incorporates corresponding subtypes based on the preservation of the autonomic nerve. Our surgical classification unifies the pelvic membrane anatomical terminology, validates the feasibility of classifying rectal cancer surgery using the theory of "four fasciae and three spaces," and lays the theoretical groundwork for the future development of unified and standardized classification of radical pelvic tumor surgery.
Collapse
Affiliation(s)
- Jiaqi Wang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Hailong Liu
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Ajian Li
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Huihong Jiang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Yun Pan
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Xin Chen
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Lu Yin
- Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Moubin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| |
Collapse
|
2
|
Yang H, Zhang Z, Fu W, Zhang X, Sun Y, Zhang Q. Procedural dissection of the ureterohypogastric nerve fascia for locally advanced rectal cancer with adnexal infiltration: A video vignette. Colorectal Dis 2023; 25:328-330. [PMID: 35984733 DOI: 10.1111/codi.16305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/10/2022] [Accepted: 07/27/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Hongjie Yang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Zhichun Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Wenzheng Fu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Xipeng Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Yi Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Qinghuai Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| |
Collapse
|
3
|
Sun Y, Yang H, Zhang Z, Li J, Wei H, Li P, Zhou Y, Zeng Q, Xu C, Zhang X. Fascial space priority approach for laparoscopic total pelvic exenteration in patients with locally advanced rectal cancer. Surg Endosc 2022; 36:6331-6335. [PMID: 35411456 DOI: 10.1007/s00464-022-09216-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 12/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Total pelvic exenteration (TPE) with intent to achieve a pathological R0 resection is now considered as the only chance of a long-term survival for locally advanced rectal cancer (LARC) invading into adjacent organs. Lately, laparoscopic total pelvic exenteration (LTPE) is performed and achieved in several specialized centers and showed a promising application prospect. Although this is universally realized by surgeons, there are only few specialized centers to perform this complex surgery, due to concerns about the high morbidity and mortality. The techniques associated need to be disclosed and facilitated. OBJECTIVE The aim of this article is to introduce a fascial space priority approach for laparoscopic TPE step by step (with video). METHODS We describe here a fascial space priority approach for LTPE in highly selected patients with locally advanced rectal cancer. The main principle of this approach is that all of the pelvic organs are considered as a whole, the non-vascular spaces surrounding it are separated in the first place, the vascular pedicle and nerve pedicle of pelvic organs can be isolated and then transected precisely. Meanwhile, the associated key landmarks of this approach are disclosed (see the video). RESULTS The ureterohypogastric nerve fascia (UHGNF) and the vesicohypogastric fascia (VHGF) are two vital embryological planes on the lateral compartment of pelvis. The spaces on either side of them together with the retrorectal space, the space of Retzius, are all non-vascular spaces, and dissection of these spaces in LTPE surgery can be achieved simply and practicably. The ureter, the umbilical artery, the arcus tendinous fasciae pelvis (ATFP), piriformis and the puboprostatic ligament (PPL) are all important landmarks during surgery. Step-by-step illustration with precise anatomical landmarks in the present video may lead to less intraoperative blood loss and complications. CONCLUSIONS LTPE with fascial space priority approach might be a standard surgical procedure for total pelvic exenteration with clear anatomy and reduced blood loss.
Collapse
Affiliation(s)
- Yi Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Hongjie Yang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Zhichun Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Jian Li
- Department of Urological Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Hao Wei
- Department of Urological Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Peng Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Yuanda Zhou
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Qingsheng Zeng
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Chen Xu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Xipeng Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China.
| |
Collapse
|
4
|
Chen Z, Sasaki K, Murono K, Kawai K, Nozawa H, Kobayashi H, Ishihara S, Sugihara K. Oncologic Status of Obturator Lymph Node Metastases in Locally Advanced Low Rectal Cancer: A Japanese Multi-Institutional Study of 3487 Patients. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11372-z. [PMID: 35243595 DOI: 10.1245/s10434-022-11372-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer tumor-node-metastasis staging system for rectal cancer defines lateral pelvic lymph nodes (LPLNs) only in the internal iliac region as regional. However, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) staging system, also considers obturator lymph nodes (LNs) as regional. This retrospective cohort study evaluated the oncologic status of obturator LNs in low rectal cancer. METHODS The study identified 3487 patients with pT3-T4 low rectal cancer who had undergone curative resections without preoperative radiotherapy or chemotherapy between 2003 and 2011 in the JSCCR database and divided them into six groups. Overall survival (OS) and recurrence-free survival (RFS) were analyzed by groups. RESULTS Histologic LPLN metastases were identified in 8% (279/3487) of all the patients and in 18.2% (279/1530) of the patients who underwent lateral pelvic node dissection. The 5-year OS and RFS rates of the obturator-LPLN group (P = 0.095) were worse than those of the internal-LPLN group (P = 0.075), but the difference was not significant. The OS of the obturator-LPLN group was similar to that of the resectable liver metastasis group (P = 0.731), and the RFS of the obturator-LPLN group was significantly better than that of the other-LPLN group (P = 0.016). CONCLUSION The prognosis for obturator LN metastases in low rectal cancer was not significantly worse than for internal iliac LN metastases, defined as regional by the current American Joint Committee on Cancer staging system, and the oncologic status of obturator LNs warrants more studies.
Collapse
Affiliation(s)
- Zhifen Chen
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Koji Murono
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazushige Kawai
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hioaki Nozawa
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University, Mizonokuchi Hospital, Kawasaki-city, Kanagawa, Japan
| | - Soichiro Ishihara
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan.
| | | |
Collapse
|
5
|
Sun Y, Yang H, Zhang Z, Zhou Y, Li P, Zeng Q, Fu W, Zhang X. Laparoscopic Pelvic Exenteration with Bladder Sparing for Men with Locally Advanced Rectal Cancer (with Video). Ann Surg Oncol 2022; 29:3067-3068. [PMID: 34994910 DOI: 10.1245/s10434-021-11222-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/01/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this article was to introduce a fascial space priority approach for laparoscopic pelvic exenteration (PE) with bladder-sparing for men with locally advanced rectal cancer. METHODS We present a video of bladder-sparing laparoscopic PE with fascial space priority approach in a 70-year old man. The systematic de-arterialization of the prostate on the basis of complete separation of the avascular lateral pelvic spaces is introduced in detail. RESULTS The operation time was 360 min and the estimated intraoperative blood loss was 50 mL. The postoperative course was uneventful and the patient was discharged on postoperative day 14. Histopathological examination showed all margins to be tumor-free. CONCLUSIONS Bladder-sparing laparoscopic PE using a fascial space priority approach is a feasible and safe procedure that can be performed in well-selected patients following neoadjuvant chemoradiotherapy. Extensive multivisceral resection is possible without a permanent stoma.
Collapse
Affiliation(s)
- Yi Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Hongjie Yang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Zhichun Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Yuanda Zhou
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Peng Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Qingsheng Zeng
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Wenzheng Fu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Xipeng Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300121, China.
| |
Collapse
|
6
|
The feasibility and technical strategy of a fascia space priority approach in laparoscopic lateral lymph node dissection for advanced middle and low rectal cancer: a retrospective multicentre study. Wideochir Inne Tech Maloinwazyjne 2021; 16:312-320. [PMID: 34136026 PMCID: PMC8193747 DOI: 10.5114/wiitm.2021.105143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Laparoscopic lateral lymph node dissection (LLND) is an important treatment for patients with lateral lymph node metastasis. Aim To assess the technical feasibility and investigate the surgical outcomes after LLND using the fascia space priority approach for patients with advanced middle and low rectal cancer. Material and methods Consecutive patients undergoing laparoscopic LLND using the fascia space priority approach from June 2017 to June 2020 were identified from 12 medical centres in mainland China. Three anatomic fascia spaces were dissected to establish the boundaries of the LLND, and the obturator and internal iliac lymph nodes were excised in an en bloc manner. Retrospective clinical data including patient characteristics, surgical details, and pathology were analysed. Results A total of 112 patients were identified. All surgeries were completed laparoscopically with no conversions. The mean operation time was 343.6 ±103.8 min for the entire procedure. The median blood loss was 100 ml (range: 100-700 ml). The median lymph node yield was 6 (range: 1-41), and lymph nodes were positive in 39.3% (44/112) of the patients. Sixteen (14.3%) patients had Clavien-Dindo I-II complications, no Clavien-Dindo III-IV complications were identified. The incidence of complications between the bilateral dissection group and the unilateral dissection group was not statistically different (p = 0.19). The complication rate between the "nCRT" group and the "no nCRT" group was not significantly different (p = 0.62) either. There were no perioperative deaths. Conclusions Laparoscopic LLND using the fascia space priority approach is feasible and safe for patients with lateral lymph node metastasis.
Collapse
|
7
|
Sun Y, Yang HJ, Zhang ZC, Zhou YD, Li P, Zeng QS, Zhang XP. Fascial space priority approach for laparoscopic supralevator posterior pelvic exenteration with nerve sparing: anatomy and technique. Tech Coloproctol 2021; 25:747-748. [PMID: 33515339 DOI: 10.1007/s10151-020-02406-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/28/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Y Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - H J Yang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Z C Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Y D Zhou
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - P Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Q S Zeng
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - X P Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China.
| |
Collapse
|
8
|
Li P, Zhang Z, Zhou Y, Zeng Q, Zhang X, Sun Y. Metastasis to lateral lymph nodes with no mesenteric lymph node involvement in low rectal cancer: a retrospective case series. World J Surg Oncol 2020; 18:288. [PMID: 33158448 PMCID: PMC7648421 DOI: 10.1186/s12957-020-02068-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/26/2020] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The aim of this study is to examine the pattern of lymph node metastasis (lateral vs. mesenteric lymph nodes) in low rectal cancer. METHODS This retrospective analysis included all patients undergoing laparoscopic total mesorectal excision plus lateral lymph node dissection for advanced low rectal cancer (up to 8 cm from the anal verge) during a period from July 1, 2017, to August 31, 2019, at the Department of Colorectal Surgery, Tianjin Union Medical Center. The decision to conduct lateral lymph node dissection was based on positive findings in preoperative imaging assessments. RESULTS A total of 42 patients were included in data analysis. Surgery was successfully completed as planned, without conversion to open surgery in any case. A minimum of 10 mesenteric lymph nodes and 1 lateral lymph node on each side were dissected in all patients. Pathologic examination of resected specimens showed no metastasis to either mesenteric or lateral lymph nodes in 7 (16.7%) case, metastasis to both mesenteric and lateral lymph nodes in 26 (61.9%) cases, metastasis to mesenteric but not lateral lymph nodes in 4 (9.5%) cases, and metastasis to lateral but not mesenteric lymph nodes in 5 (11.9%) cases (n = 2 in the obturator region; n = 3 in the iliac artery region). CONCLUSION A clinically significant proportion of low rectal cancer patients have metastasis to lateral lymph nodes without involvement of mesenteric lymph nodes. More carefully planned prospective studies are needed to verify this preliminary finding.
Collapse
Affiliation(s)
- Peng Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Zhichun Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Yuanda Zhou
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Qingsheng Zeng
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China
| | - Xipeng Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China.
| | - Yi Sun
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, 300000, China.
| |
Collapse
|