Brazilian Journal
Brenner et al.
of Videoendoscopic

Total Ressection of the Mesorectum with
Laparoscopic Endo-Anal Pull-Through in the Treatment
of Distal Rectal Cancer
Ressecção Total do Mesorreto com Abaixamento Endo-Anal
Videolaparoscópico no Tratamento do Câncer do Reto Distal
Adjunct Professor, Evangelical Faculty of Medicine of Paraná. 1. Adjunct Professor of Surgery and Physician, Hospital de Clínicas, Federal University of Paraná (UFPR). Adjunct Professor of Surgery, Evangelical Faculty of Medicine of Paraná. Master’s and Doctorate in Surgery from Federal University of Paraná (UFPR). Post-Doctorate studies at the Cleveland Clinic Foundation, OH, USA; 2. Resident, Coloproctology, Evangelical Hospital, Curitiba, PR; 3. Physician and Director of Urgent Care, Vita Hospital, Curitiba, PR; 4. Emeritus Professor, Department of Surgery, Hospital de Clínicas, UFPR. ABSTRACT
: To describe the technique of endo-anal pull-through of the rectum performed by a laparoscopic approach in
a patient with adenocarcinoma of the distal rectum. We also present and discuss the various techniques of colon pull-
through proposed to date. Discussion: Colo-anal anastomosis remains a challenge with implications for sphincter
function. Many variations of the technique have been described and can be used provided they consider the clinical
characteristics of the patient, the patient’s personal choice, and the experience of the surgeon. Laparoscopy can be
employed in pull through surgeries of the colon without the need for stoma or auxiliary incisions.
Key words: Laparoscopy. Rectal Neoplasms. Endo-anal pull-through.
Braz. J. Video-Sur, 2013, v. 6, n. 2: 086-091
Accepted after revision: february, 13, 2013. INTRODUCTION
common and socially limiting. There is a greatertechnical difficulty and critical irrigation of the pulled- Advances in the treatment of rectal cancer have through colon. Fistulas occur in up to 20% of cases, enabled the reconstruction of bowel transit, even and late complications include stenosis. These with the most distal tumors, without compromising complications can lead to new surgeries, permanent survival. Laparoscopic surgery has evolved so that or temporary colostomy, and increase the chance of surgical trauma is minimal and recuperation faster and cancer recurrence.2 Stomata are typically considered less painful. There is less risk of herniations or the temporary, and thus imply additional reversal surgery formation of adhesions, beyond the aesthetic and that is not without risks or complications. Additional hospitalizations for stenosis or anastomotic fistula are Ultra-low anastomosis performed with staplers, common. The impossibility of closing temporary colonic pull-through and intersphincter resections are technical options in sphincter preservation that are innovations, such as the colonic pouch, have reducing the need for perineal amputation and contributed to reducing complications and sequelae.4,5,6 permanent colostomy.1 More precise data and longerfollow-up, however, are still needed to evaluate the CASE DESCRIPTION
impact of these procedures in terms of the rates oflocal recurrence and measures of sphincter function.
EMCJ, male, age 64, a native and resident of The low colo-anal anastomosis has several Curitiba, Paraná was treated for distal rectal drawbacks. The occurrence of incontinence is adenocarcinoma first diagnosed two years ago. There Total Ressection of the Mesorectum with Laparoscopic Endo-Anal Pull-Through in the Treatment of Distal Rectal Cancer was no family history of cancer or polyps. He denied dissection of the rectum respecting the planes and smoking and drinking. His past medical history included sections of the Total Mesorectal Excision (TME). For type II diabetes, hyperlipidemia and hypertension. He this case of a male patient, with a long and narrow had undergone myocardial revascularization surgery pelvis, a Pfannenstiel incision was necessary, so we and prostatectomy for benign prostatic hyperplasia; could advance the TME to the level of elevators in all The patient was initially managed by another adrenaline solution (at a concentration of 1:200,000) chemotherapy. The lesion was then staged as into the submucosa of the distal rectum and anal ca- uT1N0M0 and the patient underwent local resection nal. We dissected the submucosa in its entire followed by adjuvant chemotherapy. Fourteen circumference and sectioned the distal rectum 2 cm months later, follow-up tests revealed a new lesion below the tumoral margin, aiming to preserve most of in the distal rectum associated with an elevated the sphincter muscles, without violating the oncologic carcinoembryonic antigen (CEA) level. Colonoscopy revealed a new elevated sessile lesion in the scar of The rectum and colon were then pulled and the previous local resection which was biopsied.
exteriorized transanally (Figure 1). The sigmoid Several small polyps were also identified in the left colon was sectioned and attached to the anal canal colon and were resected endoscopically. The with separate nonabsorbable sutures. A compressive anatomic pathology confirmed the lesion of the dressing was applied to the exteriorized colonic rectum as moderately differentiated adenocarcinoma and described the polyps as tubular adenomas without The patient had an uneventful postoperative high-grade dysplasia. One metastatic lesion was course despite the development of small areas and diagnosed in the upper lobe of the left lung and foci of necrosis in the colonic stump. The necrotic areas were debrided every other day or as needed.
The patient evolved without abdominal complaints and revealed hypermetabolism in the left posterolateral wall had several pasty evacuations per day until the 30th of the lower rectum and anal canal, a liver metastasis postoperative day, when we performed the amputation in segment VIII, and a lung metastasis in the superior of the colonic stump suturing the colon to the anal segment of the left upper lobe. After administration canal, with separate absorbable sutures. On the same of a new chemotherapy regimen, there was complete occasion, the patient also underwent resection of the regression of hepatic lesion, but the left apical pulmonary nodule by open thoracotomy.
The patient had a favorable postoperative In our care, the patient was staged again using course. The patient reported pasty stools with an endorectal ultrasonography and MRI as yT3N0M1.
incontinence score of 15 using the Cleveland Clinic
On examination, the patient was in good general Florida fecal incontinence score system. The
condition, had a ruddy complexion and was wellhydrated. The abdomen was flat, soft and non-ten-der. There were no palpable masses. Visual inspectionof the anal canal was normal; on digital rectalexamination, however, a hard fixed posterior lesion,located approximately 3.5 cm from the anal marginwas palpable.
Surgical Procedure
The patient was placed in Lloyd-Davies
position under general anesthesia. Four trocars wereplaced: right flank, right iliac fossa, left flank, and theoptic in the umbilical position. We ligated the inferiormesenteric artery and vein at their origins anddissected the splenic flexure. This was followed by Figure 1 - Exteriorized colonic stump.
Brenner et al.
patient uses garment liners as a precaution, but reports rectum through a perineal approach, followed by telescoping of the colon. The anastomosis wasperformed through a perineal approach 2 or 3 cm from DISCUSSION
the pectineal line, followed by introduction of the colonicstump in the pelvic cavity.
There are several procedures that can be used to treat cancer of the medial and distal rectum. It is through of the colon when a cuff of rectal mucosa up to the surgeon to choose that which is best suited extending 3 to 4 cm above the pectineal line was to the case in question. It is therefore important that resected and the colon pulled-through inside this the surgeon know the different techniques available rectum devoid of mucosa, which allows adhesion of so that the treatment of each case can be the muscle of rectum to the serosa of the pulled- through colon. The colonic stump remains exteriorized Several surgeons contributed to making the for 18 days.12 This technique was used by several ultra-low colo-anal anastomosis feasible and safe. In the late nineteenth century, Maunsell developed a colon In Brazil, this technique was performed by pull-through operation with inversion of the rectum, resulting in a delayed colorectal anastomosis. In 1902 megacolon and by Habr-Gama for rectal cancer.13- Weir modified the Maunsell operation, using an abdo- 16 Similarly Vasconcelos in 1961 performed an minal approach. The colonic stump remains abdominoperineal rectosigmoidectomy through an exteriorized for 12 days (on average), to then be abdominal approach, removing the rectal mucosa up resected and reintroduced into the pelvic cavity. The to the anal canal and pulling the colon down into the technique of rectosigmoidectomy with delayed rectum.17 A similar technique was described by anastomosis was modified by Turnbull (Cleveland Clinic) and by Cutait (São Paulo University) in 1961.7,8 It is used for treatment of both rectal cancer and rectal pull-through surgery, which preserves the acquired megacolon. After mobilization of the entire rectum. The operation entails the detachment of the colon and rectum by an abdominal approach, the retro-rectal space to the level of the levator muscles rectum is everted and sectioned 3-4 cm from the of the anus, sectioning and closing the rectum at the level of the peritoneal reflection, and preparing the vascular arcade of the segment of the colon to be telescoping the colorectal segment which is attached pulled through. Using a perineal approach, a poste- to the edge of the sectioned rectum. After 2 to 3 rior submucosal detachment is performed, respecting weeks the stump is amputated close to the anus and the sphincter apparatus to the level of the puborectal the colonic mucosa is sutured to the rectum. Recent ligament of the elevator muscle of the anus. Then results of 67 patients who underwent the Turnbull- an opening is made in the muscular wall of the rectum Cutait pull-through, report the occurrence of fistulas at this level, thus reaching the pre-sacral space in 7% and failure of the surgery in 25% (16% stenosis through which the colon is pulled through. Altmeier and Martin (1962), Grob (1960), and Haddad (1968) In 1932, Babcock proposed the transanal pull- proposed modifications to Duhamel’s original through and the Parks proposed the primary colo-anal anastomosis. In 1999 Baulieux described delayed colorectal anastomosis performed one week after the described 80 years ago, but seem to have been primary procedure.2 In 1940, Correa Netto10 was the forgotten. They do not pose oncologic risks, do not first Brazilian to perform the pull-through operation require a protective ileostomy, and can avoid the mini- after intersphincter perineal amputation of the rectum.
incisions typical of laparoscopic surgery.
The technique was used for the treatment of acquired For the patient in question, we opted for the endoanal pull-through of the colon. This technique was described by Mandache and used by Habr-Gama.
abdominoperineal rectosigmoidectomy with removal 12, 16 The postoperative course was uneventful. The of the colon distended by eversion and section of the endo-anal pull-thorough of the colon does not require Total Ressection of the Mesorectum with Laparoscopic Endo-Anal Pull-Through in the Treatment of Distal Rectal Cancer a protective colostomy or ileostomy, because a perineal anastomoses below 6 cm from the anal margin, colostomy is performed. Important oncologic details occurring in up to 60% of these patients.24 Inverted such as the ligation of the inferior mesenteric artery double stapling can lower the risk of incontinence at its origin and total mesorectal excision must be caused by excessive dilation during placement of respected. The release of the splenic flexure is critical, instruments with possible damage to autonomic as is the certainty of preserving a marginal arcade to nerves. Resection of the transitional zone, assure an adequate vascularization of the segment of hemorrhoids, or part of the internal sphincter, as well the colon pulled through. These are important details as pre-operative radiation therapy, all can contribute that impose additional technical difficulty when the to the incontinence frequently observed post- operation is performed laparoscopically.
operatively. The risk of incontinence (also present The most feared complication is necrosis of in cases of primary colo-anal anastomosis) is the pulled-through segment of the colon which can frequently reported as temporary, especially in the progress to infection of the pelvic cavity, with abscess first year after surgery.25 By the 60th postoperative and fistula formation. Any suggestion of such necrosis day the patient, using 2-4 mg of loperamide daily, requires urgent revision of the pull-through. With a reported having one bowel movement a day.
viable pulled through colon the anastomotic dehiscence Although the fecal incontinence he reports is rate is very low. Adhesion occurs between the serosa exclusively nocturnal, he chose to use a garment liner of the pulled-through colon and the muscle of the The adhesion scar between the serosa of the second intention approximately 30 days after excision pulled-through colon and the muscle of the rectum of the mesorectum. The delayed anastomosis should be complete around the entire circumference performed on the 6th postoperative day reported and firm. The cutting and suturing is performed 2 to 3 anastomotic fistulae occurring in only 3% of cases.2 Facy e cols. operated 17 patients with anastomosis performed on the 5th postoperative day. They primarily a way of avoiding the risks associated with described one case of ischemia of the pulled-through the high rates of fistula and stenosis after primary colon, two deep pelvic abscesses, and one fistula suture, complications that frequently result in connecting the colo-anal anastomosis and the vagi- permanent colostomy. Technical advances and progress in pre-and postoperative care have decreased the incidence of complications, but the low colo-anal laparoscopic application of the endo-rectal pull- anastomosis continues to have disappointing statistics.
through. The delayed colo-anal anastomosis is In the 1960s the incidence of anastomotic leaks after safer, since, practically speaking, there is no risk a rectosigmoidectomy was as high as 42%. This rate of fistula. There is also no need for protective has declined to up to 20% in recent publications.2 To colostomy or ileostomy. It is an alternative to avoid severe septic complications most surgeons prefer perineal amputation of the distal rectum, as long as it does not increase the risk of cancer New techniques and materials have emerged, recurrence. And there is still the possibility of but most are still undergoing clinical evaluation.
removing the tumor through an anal approach, Anastomoses using compressive, biodegradable, or completing the procedure without incisions other magnetic (magnoanatomosis) rings or clips; doxycycline-coated sutures; staple-line reinforcement by banding or using an electric welding anastomosis laparoscopic endo-anal pull-through is technically feasible and a reasonable option, especially in patients Fecal incontinence is also more common in at risk for anastomotic complications or who refuse a patients who undergo resection with rectal Brenner et al.
Descrevemos a técnica do abaixamento endo-anal do reto realizado por acesso laparoscópico em um
paciente portador de adenocarcinoma do reto distal. Também apresentamos e discutimos as várias técnicas de
abaixamento do cólon propostas até o momento. Discussão: A anastomose colo-anal permanece um desafio com
implicações na função esfincteriana. Muitas variações técnicas foram descritas e podem ser utilizadas desde que
respeitem critérios considerando as características clínicas do paciente, opção pessoal do paciente e a experiência do
cirurgião. A videocirurgia pode ser empregada também nas cirurgias de abaixamento do cólon, sem a necessidade de
ostomia ou de incisões auxiliares.
Palavras chave: Laparoscopia. Neoplasia retal. Abaixamento endo-anal.
12. Mandache F, Prodesco V, Constantinescu S. Anastomose colo-anal sans suture. Presse Med. 1959; 66:1583-1584.
Chen JC, Chen JB, Wang HM. Laparoscopic coloanal 13. Mendonça T. Técnica de Duhamel na cirurgia do megacólon anastomosis for low rectal cancer. JSLS. 2002 Oct-Dec; adquirido (tema livre). In Congresso Brasileiro de Coloproctologia XVI, São Paulo, 1966.
Jarry J, Faucheron JL, Moreno W, Bellera CA, Evrard 14. Simonsen O, Habr A & Gazal P. Retossigmoidectomia S.Delayed colo-anal anastomosis is an alternative to endoanal mcom ressecção da mucosa retal. Ver. Paul. Med.
prophylactic diverting stoma after total mesorectal excision for middle and low rectal carcinomas. Eur J Surg Oncol. 2011 15. Raia A. Estado atual de La cirurgia Del megacolon. Prensa Feb; 37(2):127-33. Epub 2010 Dec 24.
Fischer A, Tarantino I, Warschkow R, Lange J, Zerz A, Hetzer 16. Habr-Gama A. Indicações e resultados da retocolectomia FH. Is sphincter preservation reasonable in all patients with abdominoendoanal no tratamento do câncer do reto. Tese.
rectal cancer? Int J Colorectal Dis. 2010 Apr; 25(4):425-32.
17. Vasconcelos E. Nova técnica de abaixamento do cólon sem Tafiampas P, Christodculakis M, Tsiftsis DD. Anastomotic sutura no megacólon. Ver. Hosp. Clin. Fac. Med. Univ. São leakage ofter low anterior resection for rectal cancer: facts, obscurity and fiction. Surg Today. 2009; 39(3):183-8.
18. Soave, F. Une nouvelle téchnique chirurgicale pour La Ho YH, Ashour MA. Techniques for colorectal anastomosis.
traitement de La maladie de Hirshprung. J. Chir. 1960; 57:116- World J Gastroenterol 2010 Apr 7; 16(13):1610-21.
Prete F, Prete FP, De Luca R, Nitti P, Sammarco D, Preziosa 19. Duhamel, B. Une nouvelle opération pour Le meégacôlon G. Restorative proctectomy with colon pouch-anal congenital: l’abaissement retro-rectal et trans-anal du colon anastomosis by laparoscopic transanal pull-through: an et son application possible au traitement de quelques autres available option for low rectal cancer? Surg Endosc. 2007 malformations. Presse méd. 1956; 64:2249-2250.
20. Martin LW & Altemeier WA. Clinical experience with a new Cutait DE. Technique of rectosigmoidectomy for megacolon: operation (modified Duhamel procedure) for the report of 425 resections. Dis. Colon Rect. 1965; 8:107-114.
Hirschsprung´s disease. Ann Surg. 1962; 156:678-681.
Turnbull Jr RB. “Pull-through” resection of the rectum with 21. Grob M. Intestinal obstruction in the newborn infant. Arch delayed anastomosis for cancer or Hirschprung’s disease.
22. Haddad J. Tratamento do megacolo adquirido pelo abaixa- Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio VW.
mento retro-retal do colo com colostomia perineal. Operação Outcomes following Turnbull-Cutait abdominoperineal pull- de Duhamel modificada. Tese. Fac. Med. Univ. S. Paulo, through compared with coloanal anastomosis. Br J Surg.
23. Chang D, Zhang Y, Dang C, Zhu K, Li K, Chen D, Chen W.
10. Correia Netto A. Um caso de megacolon curado pela ampu- Prevention of anastomotic leakage after low anterior resection tação perineal interesfincteriana do reto. Ver. Med. S. Paulo.
in rectal cancers. Hepatogastroenterology. 2010 May-Jun; 11. Swenson o & Bill Jr AH. Resection of rectum and 24. Hiranyakas A, Ho YH. Laparoscopic ultralow anterior rectosigmoid qith preservation of the sphincter for benign resection versus laparoscopic pull-through with coloanal spastic lesion producting megacolon. An experimental study.
anastomosis for rectal cancers: a comparative study. Am J Total Ressection of the Mesorectum with Laparoscopic Endo-Anal Pull-Through in the Treatment of Distal Rectal Cancer 25. Gross E, Dahlberg M, Glimelius B, Graf W, et al. Preoperative Corresponding author:
irradiation affects functional results alter surgery for rectal cancer. Dis Colon Rectum 1998; 41:543–51.
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Brazilian Journal of Videoendoscopic Surgery - v. 6 - n. 2 - Apr./Jun. 2013 - Subscription: + 55 21 3325-7724 - E-mail: 1983-9901: (Press) ISSN 1983-991X: (on-line) - SOBRACIL - Press Graphic & Publishing Ltd. Rio de Janeiro, RJ-Brasil


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