Results

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RESULTS

RatesofpainreliefandfissurehealingforclosedLISareequivalenttothe opentechnique,andrangefrom90%to100%.Fissurerecurrenceafter closedLISis<10%.Theseratesaresuperiortononoperativetreatmentas wellasbotulinumtoxininjectionandtheanalstretchtechnique,whichis referencedforhistoricalinterestonly.Long-termqualityoflifeand patientsatisfactionscoresremainveryhighafterclosedLIS.

CONCLUSIONS

ClosedLISisasafeandeffectivetreatmentforchronicanalfissures.Care shouldbetakentoavoidinjurytotheanodermandtothepractitioner. Severalvariationsintechniquecanbeusedwithequivalentoutcomes.

RECOMMENDEDREFERENCESAND READINGS

BeatyJS,ShashidharanM.Analfissure.ClinColonRectalSurg2016;29(1):30–37. Brown,CJ,DubreuilD,SantoroL,LiuM,O’ConnorBI,McLeodRS.Lateralinternal

sphincterotomyissuperiortotopicalnitroglycerinforhealingchronicanalfissureanddoesnot

compromiselong-termfecalcontinence:six-yearfollow-upofamulticenter,randomized,

controlledtrial.DisColonRectum2007;50:442–8. ChoDY.Controlledlateralsphincterotomyforchronicanalfissure.DisColonRectum

2005;48:1037–41. Garcia-AguilarK,BelmonteC,WongWD,LowryAC,MadoffRD.Openvs.closedsphincterotomy

forchronicanalfissure:long-termresults.DisColonRectum1996;39:440–3. GargP,GargM,MenonGR.Long-termcontinencedisturbanceafterlateralinternal

sphincterotomyforchronicanalfissure:asystematicreviewandmeta-analysis.ColorectalDis

2013;15:e104–17. KhubchandaniIT,ReedJF.Sequelaeofinternalsphincterotomyforchronicfissureinano.BrJ

Surg1989;76(5):431–4. MentesBB,EgeB,LeventogluS,OguzM,KaradagA.Extentoflateralinternalsphincterotomy:

uptothedentatelineoruptothefissureapex?DisColonRectum2005;48:365–70. NelsonRL,ChattopadhyayA,BrooksW,PlattI,PaavanaT,EarlS.Operativeproceduresfor

fissureinano.CochraneDatabaseSystRev2011;11:CD002199. NotarasMJ.Lateralsubcutaneoussphincterotomyforanalfissure—anewtechnique.ProcRSoc

Med1969;62:713. PerryWB,DykesSL,BuieWD,RaffertyJF.Practiceparametersforthemanagementofanal

fissures(3rdrevision).DisColonRectum2010;53(8):1110–5. WileyM,DayP,RiegerN,StephensJ,MooreJ.Openvs.closedlateralinternalsphincterotomy

foridiopathicfissure-in-ano:aprospective,randomized,controlledtrial.DisColonRectum

2004;47:847–52.

PARTVII

PRESACRALTUMORS

Chapter23

TechnicalConsiderationsin theSurgicalManagementof PresacralTumors

SkandanShanmuganandNajjiaN.

Mahmoud

INDICATIONS/CONTRAINDICATIONS

Betweenoneandsixpatientsayeararediagnosedwithtumorsthat occupythepresacralorrectrorectalspace.Olderretrospectivereports documentanincidenceaslowas1in40,000hospitaladmissions,with themajorityofcasespresentingatmetropolitan,tertiarycarecenters. Theseraretumorsaremostlybenigncystsbutcanalsobecomplex malignant,heterogeneouslesions.Presacraltumorsareindolentanddo notusuallyproduceanysignificantsignsorsymptomsuntiltheyarelarge enoughtoinvadethesurroundingpelvicstructuresandaretherefore foundtobesubstantiallylargeinsizeatthetimeoftheirdelayed diagnosis.Presacraltumorsareclassifiedintocategoriesthattendto reflectthehistologicallyheterogeneousnatureofthepresacralspace itself,whichconsistofvariousembryologicalremnants(Table23-1).They canbecategorizedascongenital,neurogenic,osseous,ormiscellaneous tumors,accordingtothemostfrequentlyusedclassificationschemeby UhligandJohnson.Thesemassesmaybecysticorsolid,withthelatter havingapredilectionformalignancyandthepediatricpopulation. Undoubtedly,themostchallengingissueforsurgeonsisthelocationof thesetumors.Thesmall,confinedspacedefinedbytheframeworkofthe lowerbonypelvishousesnerves,vessels,muscles,genitourinary,and gastrointestinalorganswithinmillimetersofoneanother.Aninvasive massinthisarearepresentsspecialtechnicalchallengesandalmost

alwaysportendsthelossoffunctionandform,eitherfromsurgeryorthe tumoritself.Clearly,theseraretumorsrequirecarefulpreoperative planningforbestshort-andlong-termoutcomes.Furthermore,recent advancesinimagingmodalities,tumorbiology,andadjuvanttherapy haveledtoanimprovedmultidisciplinaryapproachtomanagingthese tumors.Thischapterservestocategorizethesetumors,discusses preoperativeplanning,andofferstechnicalapproachesandinsightsinto surgicalresectionandreconstruction.

TABLE23-1

ClassificationofRetrorectalMasses

Congenital Inflammatory Neurogenic Osseous

Developmental cysts

Inflammatory

boweldisease

Neurofibroma Osteoma

Epidermoid cyst

Perirectalabscess

(cryptoglandular)

Neurolemmoma Osteogenicsarcoma

Dermoid cyst

Pelvirectalabscess

(descending,e.g.,

diverticulitis)

Ependymoma Sacralbonecyst

Tailgutcyst

Tuberculosis/Pott’s

disease

Ganglioneuroma Ewing’stumor

Teratoma Chordoma

Neurofibrosarcoma Giantcelltumor

Chondromyxosarcoma

Anterior meningocele Rectal duplication

Adrenalrest tumors

ModifiedwithpermissionfromUhligBE,JohnsonRL.Presacraltumorsandcystsinadults.DisColon Rectum1975;18:581.

ANATOMY

Thepelvisisdefinedbytheconfinesofitsbonystructures—thesacrum posteriorly,pubicboneanteriorly,andthesacralramilaterally(Fig.23-

1).Itisinvestedbytheendopelvicfasciaorpresacralfascia,whichresides

anteriortothesacrum.Alongthepresacralfasciarunthehypogastric nerves,whichbranchlaterallyandanteriorlytocoalescewiththeir parasympatheticcounterpartstoformthesacralplexus.Laterally,the internalandexternaliliacvesselsandtheuretersrunalongthe retroperitoneumanteriortotheiliopsoasmuscle.Presacralmassesmay residebetweenthefasciapropriaoftheposteriorrectumandthe presacralfascia.Thespaceisactuallyapotentialone,boundbythe rectum(andmesorectum)anteriorly,thepresacralfasciaposteriorly,and thelateralligamentslaterally.TheinferiorborderisWaldeyer’sfascia (retrosacralfascia)overlyingtheperinealmuscles,andthesuperior borderistheperitonealreflection.Theretrorectalspacecontains pluripotentcellsfromthefusionoftheembryologicalhindgutandthe neuroectoderm,whichcontributestothecellularheterogeneityseenin presacraltumors.Inaddition,thesemassesmayalsoarisefromosseous elementslocatedposteriorly,suchasthesacrumorcoccyxbone.

p.171

p.172

FIGURE23-1Boundariesofthepresacralspace.The

boundariesoftheretrorectalspacearethefasciapropriaof themesorectumanteriorly,thepresacralfasciaposteriorly, theperitonealreflectionsuperiorly,andWaldeyer’sfascia overlyingthelevatoranimusclesinferiorly.

(AdaptedfromNichollsJ,DoziosRR,eds.SurgeryoftheColon andRectum.Edinburgh:ChurchillLivingstone,1997.)

CongenitalLesions

Congenitallesionsarethemostcommonpresacraltumorsandaccount fortwothirdsofalltumorsinthepresacralspace.Theyarisefromthe remnantsofembryonictissuesandcanrepresentcysticlesionssuchas developmentalcystsoranteriormeningoceles.Solidcongenitallesions consistofteratomas,sacrococcygealchordomas,andadrenalresttumors. Inadults,cysticcongenitaltumorsaretypicallybenignandsolidonesare usuallymalignant.

p.172

p.173

DevelopmentalCysts

Developmentalcystsconstitutetwothirdsofthecongenitalpresacral tumorsencounteredinclinicalpractice,arealmostalwaysbenign,and haveaprominentfemalepreponderanceofapproximately5:1inmost

series.Theycanarisefromanyembryoniccelllayer.Epidermoid, dermoid,orteratomatumorsarethethreemostcommonentities,and arecomprisedofone,two,andthreeembryologicallydistinctcelllayer origins,respectively(Fig.23-2).Tailgutcystsarealsoincludedinthe developmentalcystgroup,althoughtheyarequiterare,andarederived frommesodermaltissueoftheembryonicgastrointestinaltract.Theyare alsoconsideredtoberetrorectalcystichamartomasandresultfrom failureofregressionoftheembryonictail.Dermoidandepidermoidcysts oftencontaindermalelementsandarecommonlyfilledwithasebaceouslikematerialsecretedfromglandswithinthecystwall.Dermoidcystsare themostcommonlyencounteredretrorectalmassinclinicalpractice. Theyareoftendistallylocatedandeasilyaccessible,andexcisedwitha simpleposteriorjuxtasacralincision.Teratomasoftenfeaturemature embryologicelementscomprisedofallthreeembryoniclayers.Teeth, hair,sebaceousmaterial,andbonecanbefound.Theycanbeeither cysticorsolidorhaveelementsofbothandareoftennotedtobefirmly adherenttothecoccyxevenwhenbenign.Aswithovarianteratomas, approximately5–10%undergomalignantdegeneration.Electiveexcision isrecommendedforalldevelopmentalcysts,particularlywithteratomas, wheremalignantdegeneration,asmentioned,isapossibility.Otherwise, prognosisfollowingsuccessfulresectionoftheselesionsis100%.

FIGURE23-2Sagittalviewofdermoidcystonmagnetic

resonanceimaging.Presacraldermoidcystinayoungfemale.

(CourtesyofNajjiaN.Mahmoud,UniversityofPennsylvania.)

Chordomas

Chordomasarethemostcommonmalignantlesionsinthepresacral spaceandarisefromtheembryologicnotochord,with30–50%occurring inthesacrococcygealregion(Fig.23-3).Theseslow-growinginvasive tumorshavea2:1predilectionformalesduringtheagesof40–60. Patientspresentwithsymptomsimplyingneurologicinvolvement characterizedbypain,urinaryincontinenceorretention,andimpotency orerectiledysfunction.Lowerextremityparalysistendstobeuncommon unlessthetumorislocatedinthelumbarorthoracicvertebrae.Thirtyto fiftypercentofchordomasarelocatedinthesacrococcygealregion. Chordomasarequiteresistanttochemotherapyandinsensitivetopelvic radiation,thusradicalresectionrepresentstheonlyprocessforcure,but sometimesresultinginmotorandsensorydysfunction.Survivalrates afterchordomaresectionhavebeenrising.Inthe1970s,recurrencerates werereportedinexcessof90%andsurvivalwas<20%followinga diagnosis.Advancesinimaging,surgery,andreconstructionhavebeen creditedwithimprovingsurvivalfourfold.Evenso,recurrenceratesat5 yearsareashighas40–70%.Survivalafterlocalrecurrenceisrare.

FIGURE23-3Sagittalcomputedtomographic(CT)image

ofachordoma.SagittalreformattedCTimageshowsthemass arisingfromthesacrum,withlargepresacral(solidarrow)and smallerpostsacral(dottedarrow)soft-tissuecomponents.

(FarsadK,KattapuramSV,SacknoffR,OnoJ,NielsenGP.

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