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    8 views8 pages

    Roullier Classification

    Uploaded by

    Keam Pisethsapheareach

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    CIR Low Rectal Cancer: Classification and Standardization of Surgery Eric Rullier, M.D.'* + Quentin Denost, M.D." + Véronique Vendrely, M.D.* Anne Rullier, M.D., Ph.D. « Christophe Laurent, M.D., Ph.D.1? 1 Surgery Department, CHU Bordeaux, Saint-Andre Hospital, Bordeaux, France 2 Bordeaux Segalen University, Bordeaux, France 5 Radiotherapy Department, CHU Bordeaux, Hast-Leveque Hospital, Rese, France 4 Pathology Department, CHU Bordeaus, Pellegrin Hospital. Bordeaux, France BACKGROUND: Surgical treatment of low rectal cancer is controversial, and one of the reasons is the lack of defini- tion and standardization of surgery in low rectal cancer. OBJECTIVE: We classified low rectal cancers in 4 groups ‘with the aim of demonstrating that most patients with low rectal cancer can receive conservative surgery without compromising oncologic outcome. DESIGN: Patients with low rectal cancer <6em from anal verge were defined in 4 groups: type I (supra-anal ‘tumors: >1 cm from anal ring) had coloanal anastomosis, ‘type II (juxta-anal tumors: 20 years, Surgical management of low rectal cancer, including neoadjuvant therapy and ISR, is composed of the 3 following steps: (1) classification of low rectal cancer in 4 types; (2) standardization of surgery in 4 operations; and (3) anticipation of the type of surgery before and decision after neoadjuvant treatment. From January 1, 1994, to December 31, 2009, we cor sidered all ofthe patients treated by rectal excision for low rectal adenocarcinoma within 6cm from the anal verge. Patients with early disease (T1) conventionally treated by local excision in France and those with synchronous me- tastases (M1) were excluded from the study. Classification of Low Rectal Cancer The new and original surgical classifications of low rectal cancer separate patients with rectal cancer <6cm from the anal verge into 4 groups according to the location of the tumor from the anal sphincter (Table 1 and Fig. 1) The anal sphincter or surgical anal canal begins at ‘the anal margin (junction between the perineal skin and. the anal mucosa) and finishes at the top of the anal canal (anal ring or anorectal sling). Tumor location was defined as the lowest distal part of the tumor. Type I low rectal cancers are supra-anal tumors, that is, lesions >1 em from the anal ring. Type If are juxta-anal tumors, that is, lesions Slam from the anal ring. Type II are intra-anal tumors, that is, lesions with internal anal sphincter invasion. ‘Type IV are transanal tumors, that is, lesions with external anal sphincter or levator ani muscle invasion. Staging and classification of the tumor were performed, before neoadjuvant treatment, Endorectal ultrasound and abdominal and pulmonary computed tomography scan permitted the tumor-node-metastasis/Union for Interna- tional Cancer Control staging." High-resolution magnetic resonance imaging (MRI) was used to determine surgical margins, especially the accurate distance between the tu- mor and the different components of the anal sphincter. The anorectal ring was defined clinically as the top of the squeeze pressure and was obtained by digital examination with voluntary contraction. It was defined radiologically as the top of the anal canal identified by MRI or ultra- sound at the upper border ofthe external sphincter and at 561 Senne Glasfeation Definition Surgical procedure Type Supra-analtumor can > em from anal ing Typell ——_Juxta-analtumor pik <1 emfrom anal ring Typell ——Invaranal tumor se Internal sphincter invasion Type Tansanal tumor 4PR Extemalsphinete invasion Cea conventonl clear anastomosis R= partalloesphneercresecten the lower end of the levator muscles. The intersphincteric plane was the space between the internal and the external sphincter, Preservation of the levator ani muscles and the intersphincteric plane at MRI was the key point to differ- entiate types I, I, and II low rectal cancers suitable for sphincter-preserving surgery from type IV treated by APR. Patients with radiological circumferential margin >1mm from the levator ani muscles and a free intersphincteric plane at MRI were considered for sphincter-preserving surgery, whereas those with involved circumferential mar- in or intersphincteric plane were treated by APR. Standardization of Surgery Conventionally low rectal cancers are treated by APR. ‘Theoretically only type I low rectal cancers (supra-anal tumors) can receive a conservative approach, because of the oncologic rule of a 1-cm distal resection margin."! Introduction of the ISR technique modified the concept of sphincter-preserving surgery, which can be proposed ‘to more distal tumors." We, therefore, defined 4 surgical procedures, each dedicated to 1 type of low rectal cancer (lable 1 and Fig. 1) ‘Type ow rectal cancers were treated bya conventional co- Toanal anastomosis (CAA), that is, a Park procedute, including anal mucosectomy above the dentate line and preservation of | the anal internal sphincter.” Type II low rectal tumors under- ‘went partial SR (pISR) to achieve sphincter-preserving surgery with >1-cm distal resection margin. Type II esions involving the internal anal sphincter had a total SR ({SR) removing the ‘whole of the internal sphincter" and type IV lesions invol- ing striated skeletal muscles (external anal sphincter or leva- tor ani muscles) were treated by APR. In patients treated by sphincter-preserving surgery, reconstruction included a pouch, Inand-sewn coloanal anastomosis with a pelvic presacral drain and a loop ileostomy for 2 months. Surgery was performed using the laparoscopic approach since 2000.* Neoadjuvant Treatment ‘Neoadjuvant treatment was used in locally advanced disease, that is, uT3T4 or UN+ disease, as recommended, 562 a Senco hasan Low Rac Cascna FIGURE 1. Surgical classification of low rectal cancer. Type | are supra-anal tumors (> 1 1cm from the anal ring or >2em from the dentate line and type II as either

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