Abstract
PURPOSE: We examined the frequency, mode, and extent of discontinuous spread of rectal cancer in the mesorectum to determine the optimal distal clearance margin in situ. METHODS: Forty consecutive patients with rectal cancer undergoing locally curative resection were studied prospectively. Discontinuous cancer spread in the mesorectum and the extent of distal spread was examined microscopically. A tissue shrinkage ratio comparing the distal clearance margin measured before transection to that measured after fixation in each case, was used to convert microscopically measured extent of distal spread to extent in situ. RESULTS: Discontinuous cancer spread in the mesorectum was observed in 17 cases (43 percent); lymph node metastasis in 15 cases (38 percent) and small deposits other than nodal metastases in 8 cases (20 percent). Distal cancer spread (either intramural or mesorectal) was observed in 6 cases (15 percent). The mean distal clearance margin before transection and after fixation was 3.2 cm and 2 cm, respectively. The mean tissue shrinkage ratio was 60 percent. The maximum extent of microscopic distal spread and adjusted distal spread in situ were 20 and 24 mm, respectively. CONCLUSIONS: Excising the mesorectum with fascia propria circumferentially intact is essential for rectal surgery. The optimal distal clearance margin for the rectal wall as well as the mesorectum in situ can be reduced to 3 cm with a right angle.
Similar content being viewed by others
References
O Søreide J Norstein (1997) ArticleTitleLocal recurrence after operative treatment of rectal carcinoma J Am Coll Surg 184 84–92
JV Reynolds WP Joyce J Dolan K Sheahan JM Hyland (1996) ArticleTitlePathological evidence in support of total mesorectal excision in the management of rectal cancer Br J Surg 83 1112–1115
JL McCall MR Cox DA Wattchow (1995) ArticleTitleAnalysis of local recurrence rates after surgery alone for rectal cancer Int J Colorectal Dis 10 126–132
RJ Heald EM Husband RD Ryall (1982) ArticleTitleThe mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69 613–616
K Havenga MC DeRuiter WE Enker K Welvaart (1996) ArticleTitleAnatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer Br J Surg 83 384–388
RJ Heald BJ Moran (1998) ArticleTitleEmbryology and anatomy of the rectum Semin Surg Oncol 15 66–71
IP Bissett KY Chau GL Hill (2000) ArticleTitleExtrafascial excision of the rectum Dis Colon Rectum 43 903–910
I Lindsey RJ Guy BF Warren NJ Mortensen (2000) ArticleTitleAnatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon Br J Surg 87 1288–1299
P Quirke P Durdey MF Dixon NS Williams (1986) ArticleTitleLocal recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical margin Lancet . 996–999
WE Enker (1997) ArticleTitleTotal mesorectal excision—the new golden standard of surgery for rectal cancer Ann Med 29 127–133
F Lopez-Kostner IC Lavery GR Hool LA Rybicki VW Fazio (1998) ArticleTitleTotal mesorectal excision is not necessary for cancers of the upper rectum Surgery 124 612–618
PJ Hainsworth MJ Egan WJ Cunliffe (1997) ArticleTitleEvaluation of the policy of total mesorectal excision for rectal and rectosigmoid cancers Br J Surg 84 652–656
JL McCall (1997) ArticleTitleTotal mesorectal excision Aust N Z J Surg 67 599–602
NS Williams MF Dixon D Johnson (1983) ArticleTitleReappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum Br J Surg 70 150–154
PM Madsen J Christiansen (1986) ArticleTitleDistal intramural spread of rectal carcinomas Dis Colon Rectum 29 279–282
PB Paty WE Enker AM Cohen GY Lauwers (1994) ArticleTitleTreatment of rectal cancer by low anterior resection with coloanal anastomosis Ann Surg 219 365–373
ND Karanjia DJ Schache WR North RJ Heald (1990) ArticleTitle“Close shave” in anterior resection Br J Surg 77 510–512
J Warneke NJ Petrelli L Herrera (1989) ArticleTitleLocal recurrence after sphincter-saving resection for rectal adenocarcinoma Am J Surg 158 3–5
K Søndenaa KH Kjellevold (1990) ArticleTitleA prospective study of the length of the distal margin after low anterior resection for rectal cancer Int J Colorectal Dis 5 103–105
JL Weese MG O’Grady FD Ottery (1986) ArticleTitleHow long is the five centimeter margin? Surg Gynecol Obstet 163 101–103
N Scott P Jackson T al-Jaberi MF Dixon P Quirke PJ Finan (1995) ArticleTitleTotal mesorectal excision and local recurrence Br J Surg 82 1031–1033
J Hida M Yasutomi T Maruyama K Fujimoto T Uchida K Okuno (1997) ArticleTitleLymph node metastases detected in the mesorectum distal to carcinoma of the rectum by the clearing method J Am Coll Surg 184 584–588
H Ueno H Mochizuki S Tamakuma (1998) ArticleTitlePrognostic significance of extranodal microscopic foci discontinuous with primary lesion in rectal cancer Dis Colon Rectum 41 55–61
JN Wiig E Carlsen O Søreide (1998) ArticleTitleMesorectal excision for rectal cancer Semin Surg Oncol 15 78–86
DF de Haas-Kock CG Baeten JJ Jager (1996) ArticleTitlePrognostic significance of radial margins of clearance in rectal cancer Br J Surg 83 781–785
NS Williams (1984) ArticleTitleThe rationale for preservation of the anal sphincter in patients with low rectal cancer Br J Surg 71 575–581
K Shirouzu H Isomoto T Kakegawa (1995) ArticleTitleDistal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery Cancer 76 388–392
JC Penfold (1974) ArticleTitleA comparison of restorative resection of carcinoma of the middle third of the rectum with abdominoperineal excision Aust N Z J Surg 44 354–356
Author information
Authors and Affiliations
About this article
Cite this article
Ono, C., Yoshinaga, K., Enomoto, M. et al. Discontinuous Rectal Cancer Spread in the Mesorectum and the Optimal Distal Clearance Margin in Situ . Dis Colon Rectum 45, 744–749 (2002). https://doi.org/10.1007/s10350-004-6290-1
Issue Date:
DOI: https://doi.org/10.1007/s10350-004-6290-1