Preoperative staging is now an essential factor in the multidisciplinary management of rectal cancer because tumor stage is the strongest predictive factor for recurrence. Preoperative staging of rectal cancer can be divided into either local or distant staging. Local staging incorporates the assessment of mural wall invasion, circumferential resection margin involvement, as well as the nodal status for metastasis. Distant staging assesses for evidence of metastatic disease. The aim of this review is to consider the indications and limitations of the current preoperative imaging modalities for rectal cancer staging including clinical examination, endorectal ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography-computed tomography, with respect to local and distant disease.

Preoperative staging of rectal cancer.

Rectal cancer: diagnosis, study and staging Rectal cancer is defi ned as a tumour located between the anal verge and 15 cm within anal verge. In rectal cancer, a precise preoperative staging allows to categorize patients for different available treatments, as well as decide the best surgical treatment. Preoperative staging is performed by several radiological tech- niques. Currently available procedures are endorectal ultrasound (EUS), computed tomography (CT) mag- netic resonance (MRI), positron emission tomography-computed tomography (PET/CT) and intraoperative ultrasound. EUS is a procedure performed by the colorrectal surgeon that allows the evaluation of the depth of tumour invasion as well as lymph node status; nevertheless its main shortcoming is the inability to assess mesorectal fascia involvement. Nowadays, MRI is the best method to assess mesorectal fascia involvement in addition to tumour invasion and lymph nodes involved. CT is a widely available procedure, and its main use is evaluation of distant metastases, with lower accuracy to assess tumour invasion and lymph node status. PET/CT is currently gaining importance, however its role in preoperative staging it's not widely accepted. IOUS allows evaluation of liver metastases during surgery, and therefore determines management and prog- nosis. Consequently, is necessary for surgeons to maintain an up-to-date knowledge of current methods, its advantages and limitations.

/pdf/cancer-de-recto-diagnostico-estudio-y-estadificacion-5f7lwj6ac6.pdf

Cáncer de recto: diagnóstico, estudio y estadificación

Since the introduction of endoanal and endorectal ultrasound by Law and Bartram in 1989, (Law and Bartram 1989) there has been an accelerated use of this technique for the preoperative assessment and management of rectal and anal cancers, (Beynon et al. 1991; Garcia-Aguilar et al. 2002) delineation of the anatomy of complex cryptogenic and inflammatory bowel disease-related perirectal sepsis (Zbar and Armitage 2006; Regadas and Regadas 2008) and for the definition of potentially reparable or augmentable external and internal sphincter defects (Martinez Hernandez Magro et al. 2003; Gravanta and Giordano 2008). Modifications of this technique with hydrogen peroxide enhancement for assessment of fistula-in-ano, (Cheong et al. 1993) Duplex supplementation for detection of perirectal blood flow, (Mallouhi et al. 2004) contrast enhancement (Chew et al. 2003), and 3-dimensional reconstruction with stacked, close interval interpolation (Zimmerman 2003; West et al. 2003; Buchanan et al. 2004) have been recent developments as has been endorectal-guided biopsy of locally recurrent rectal and anal cancers and for perirectal lymph node biopsy particularly following radiotherapy (Gavioli et al. 2000; Liersch et al. 2003). Coronal reconstruction has attempted to resolve some of the limitations inherent in endoanal sonography to provide a multiplanar interpretation of complex fistulous disease and its relationship to the main sphincter complex (Gold et al. 1999; Williams et al. 2001) and has offered useful information about staging of anal cancers prior to definitive chemoradiation (Christensen et al. 2004).

Surgeon-Performed Ultrasound in Proctologic Practice

The management of patients undergoing colorectal surgery has changed in recent decades. Efforts have been made to show that perioperative physiological stress to the patient can be minimised with s ...

/pdf/on-effectiveness-in-colorectal-surgery-mechanical-bowel-1u830gc98a.pdf

On effectiveness in colorectal surgery : mechanical bowel preparation or not in elective colonic surgery and treatment options for elderly patients with rectal cancer

Summary

Circumferential rectal cancers present at a more advanced stage than those located in a single quadrant. Although accurate staging is an important aspect of the preoperative management of the patient with a rectal cancer, the clinical and radiological staging of this subgroup of rectal cancer patients has been poorly studied. All patients with a rectal cancer were assessed clinically (by digital rectal examination and rigid sigmoidoscopy) before the radiological assessment by endorectal ultrasound (ERUS). Data collected included tumour height (distance from anal verge in centimetre) and tumour type (circumferential or non-circumferential). Radiological tumour staging was with the TNM system. Fifty-nine subjects (33 men, 26 women; median age 65 years (range 38–86 years)) were identified with a circumferential rectal cancer. Mean height of the cancer was 8 ± 0.4 cm (standard error of the mean; range 2–13 cm). Forty-two cancers were palpable, and 17 cancers were impalpable. All cancers assessed clinically as circumferential were confirmed as circumferential on ERUS scanning. Tumour stage as assessed by ERUS was either T3 (n = 57) or T4 (n = 2). Nodal status was N0 (n = 29) and N1 (n = 30). All rectal cancers assessed as circumferential on clinical examination have an ERUS stage of T3 or greater.

Clinical and endorectal ultrasound staging of circumferential rectal cancers.

Abstract Introduction Robotic cholecystectomy (RC) is a recent innovation in minimally invasive gallbladder surgery. The IDEAL (idea, development, exploration, assessment, long-term study) framework aims to provide a safe method for evaluating innovative procedures. This study aimed to understand how RC was introduced, in accordance with IDEAL guidelines. Methods Systematic searches were used to identify studies reporting RC. Eligible studies were classified according to IDEAL stage and data were collected on general study characteristics, patient selection, governance procedures, surgeon/centre expertise, and outcome reporting. Results Of 1425 abstracts screened, 90 studies were included (5 case reports, 38 case series, 44 non-randomized comparative studies, and 3 randomized clinical trials). Sixty-four were single-centre and 15 were prospective. No authors described their work in the context of IDEAL. One study was classified as IDEAL stage 1, 43 as IDEAL 2a, 43 as IDEAL 2b, and three as IDEAL 3. Sixty-four and 51 provided inclusion and exclusion criteria respectively. Ethical approval was reported in 51 and conflicts of interest in 34. Only 21 reported provision of training for surgeons in RC. A total of 864 outcomes were reported; 198 were used in only one study. Only 30 reported a follow-up interval which, in 13, was 1 month or less. Conclusion The IDEAL framework was not followed during the adoption of RC. Few studies were conducted within a research setting, many were retrospective, and outcomes were heterogeneous. There is a need to implement appropriate tools to facilitate the incremental evaluation and reporting of surgical innovation.

/pdf/quality-of-reporting-of-robot-assisted-cholecystectomy-in-233c72pi.pdf

Quality of reporting of robot-assisted cholecystectomy in relation to the IDEAL recommendations: systematic review

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Clinical and endorectal ultrasound staging of circumferential rectal cancers.

Quality of reporting of robot-assisted cholecystectomy in relation to the IDEAL recommendations: systematic review