BACKGROUND: Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins. OBJECTIVE: This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision. DESIGN AND SETTING: Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy. METHODS: A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes. RESULTS: In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no “self-opening” planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen. LIMITATIONS: The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed. CONCLUSION: The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.

PURPOSE: We investigated whether neoadjuvant chemoradiotherapy (nCRT) in patients with rectal cancer can be restricted to those at high risk of locoregional recurrence (LR) without compromising oncological outcomes. PATIENTS AND METHODS: In a prospective multicenter interventional study, patients with rectal cancer (cT2-4, any cN, cM0) were classified according to the minimal distance between the tumor, suspicious lymph nodes or tumor deposits, and mesorectal fascia (mrMRF). Patients with a distance >1 mm underwent up-front total mesorectal excision (TME; low-risk group), whereas those with a distance ≤1 mm and/or cT4 and cT3 tumors in the lower rectal third received nCRT followed by TME surgery (high-risk group). The primary end point was 5-year LR rate. RESULTS: Of the 1,099 patients included, 884 (80.4%) were treated according to the protocol. A total of 530 patients (60%) underwent up-front surgery, and 354 (40%) had nCRT followed by surgery. Kaplan-Meier analyses revealed 5-year LR rates of 4.1% (95% CI, 2.7 to 5.5) for patients treated per protocol, 2.9% (95% CI, 1.3 to 4.5) after up-front surgery, and 5.7% (95% CI, 3.2 to 8.2) after nCRT followed by surgery. The 5-year rate of distant metastases was 15.9% (95% CI, 12.6 to 19.2) and 30.5% (95% CI, 25.4 to 35.6), respectively. In a subgroup analysis of 570 patients with lower and middle rectal third cII and cIII tumors, 257 (45.1%) were at low-risk. The 5-year LR rate in this group was 3.8% (95% CI, 1.4 to 6.2) after up-front surgery. In 271 high-risk patients (involved mrMRF and/or cT4), the 5-year rate of LR was 5.9% (95% CI, 3.0 to 8.8) and of metastases 34.5% (95% CI, 28.6 to 40.4); disease-free survival and overall survival were the worst. CONCLUSION: The findings support the avoidance of nCRT in low-risk patients and suggest that in high-risk patients, neoadjuvant therapy should be intensified to improve prognosis.

Stablished a method that allows both an aseptic operation and the management of concurrent incisional hernias. METHODS: In a retrospective study we evaluated all patients who had undergone operation for a paracolostomy hernia with an expanded polytetrafluoroethylene (PTFE) mesh in the intraperitoneal onlay position in our Department of General Surgery from 1994 until 2002. Twenty patients with large paracolostomy hernias and 10 additional ventral hernias, mostly large incisional or recurrent incisional hernias, were identified. We combined the Sugarbaker and the Rives-Stoppa techniques by covering the defects with an ePTFE mesh after laparotomy and fixing the mesh with traction sutures. RESULTS: Postoperatively, there was no incidence of mesh infection. After a mean follow-up of 3½ years we found three recurrences of paracolostomy hernias and two recurrences of incisional hernias. Another two hernias emerged in the previously intact midline. All these hernias were small, without tendency to enlargement, and did not warrant reoperation. CONCLUSIONS: Patients with symptomatic paracolostomy hernias or a combination of abdominal wall defects should properly be managed surgically with an intraperitoneally placed mesh that covers all hernias. Our results, with a recurrence rate of only 15 percent for the parastomal site and 20 percent for combined defects, support this approach. e-mail: stelzner-si@khdf.de © The ASCRS 2004...