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SBA Answers and Explanations
Published in Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury, SBAs for the MRCS Part A, 2018
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury
The rectum has no mesentery and is therefore regarded as retroperitoneal. It is covered by peritoneum on its front and sides in its upper third, only on its front in its middle third and the rectum lies below the peritoneal reflection in its lower third. Do not be confused; although the rectum has no mesentery, the visceral pelvic fascia around the rectum is often referred to by surgeons as the mesorectum. The pararectal lymph nodes are found within the mesorectum, which is removed together with the rectum as a package during rectal excision for carcinoma.
Anatomy
Published in Jonathan M. Fishman, Vivian A. Elwell, Rajat Chowdhury, OSCEs for the MRCS Part B, 2017
Jonathan M. Fishman, Vivian A. Elwell, Rajat Chowdhury
The rectum has no mesentery and is therefore regarded as retroperitoneal. It is covered by peritoneum on its front and sides in its upper third, only on its front in its middle third and the rectum lies below the peritoneal reflection in its lower third. Do not be confused; although the rectum has no mesentery, the visceral pelvic fascia around the rectum is often referred to by surgeons as the mesorectum. The pararectal lymph nodes are found within the mesorectum, which is removed together with the rectum as a package during rectal excision for carcinoma.
Perianal and Anal Canal Neoplasms
Published in Philip H. Gordon, Santhat Nivatvongs, Lee E. Smith, Scott Thorn Barrows, Carla Gunn, Gregory Blew, David Ehlert, Craig Kiefer, Kim Martens, Neoplasms of the Colon, Rectum, and Anus, 2007
The most important part of diagnosis is digital examination of the anal canal. The size, consistency, and fixation of the primary lesion and the presence or absence of pararectal lymph nodes can be determined. Proctoscopy should be done to confirm the digital findings, and the exact location of the neoplasm in relationship to the dentate line should be documented. Biopsy via proctoscope or transanal excision of the neoplasm must be done to determine the histologic type of the carcinoma, thus enabling an appropriate recommendation for treatment. A colonoscopic examination should be done to rule out more proximal associated lesions. Endorectal ultrasonography is useful in evaluating the depth of invasion and detection of lymph node metastasis.
Efficacy and safety of ligation-assisted endoscopic submucosal resection combined with endoscopic ultrasonography for treatment of rectal neuroendocrine tumors
Published in Scandinavian Journal of Gastroenterology, 2022
Dazhou Li, Jiao Xie, Donggui Hong, Gang Liu, Rong Wang, Chuanshen Jiang, Zhou Ye, Binbin Xu, Wen Wang
A recent meta-analysis found that for R-NETs ≤10 mm in size and without muscular layer invasion or pararectal lymph node metastasis, minimally invasive endoscopic treatment can achieve clinical cure [3]. However, there is still no consensus on the best endoscopic resection method. Although endoscopic submucosal dissection (ESD) is an effective treatment, it has not been as frequently used in endoscopic centers or in clinical studies for the treatment of small rectal NETs as other methods such as endoscopic mucosal resection (EMR) or modified endoscopic mucosal resection (M-EMR) techniques [4,5]. The reason is that the ESD procedure is technically challenging and time taking, besides being associated with the risk of complications such as perforation and bleeding [6]. In addition, ESD has not been shown to be superior to ligation-assisted endoscopic submucosal resection (ESMR-L) in terms of complete resection rate [3]. In fact, ESMR-L is far superior to ESD for treatment of R-NETs extending into deep submucosal tissue or the muscle layer. Both EMR and ESD resection or dissection surface are located in the submucosa, whereas ESMR-L has a deeper deep resection margin than other methods [4,7].
Total mesorectal excision – 40 years of standard of rectal cancer surgery
Published in Acta Chirurgica Belgica, 2020
J. Votava, D. Kachlik, J. Hoch
The TME can be defined as a sharp dissection and a complete removal of the mesorectum, containing pararectal lymph nodes, along with its intact enveloping fascia [15]. Operative steps of the TME as described by Heald [16] are: 1. ligation of the inferior mesenteric artery at its origin; 2. mobilization of the left colic flexure; 3. transection of the left-sided colon at the junction between the descending and sigmoid colon; 4. sharp dissection in the avascular plane into the pelvis ventrally to the presacral fascia (of Waldeyer) and outside the enveloping visceral fascia of the rectum; 5. division of the lymphatic vessels and middle rectal vessels ventrolaterally at the level of the pelvic floor, 6. inclusion of all pelvic fat tissue and lymphatic structures to the level of the pelvic floor.