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RECOMMENDEDREFERENCESAND READINGS
BerghP,GunterbergB,Meis-KindblomJM,KindblomLG.Prognosticfactorsandoutcomeof
pelvic,sacra,andspinalchondrosarcomas:acenter-basedstudyof69cases.Cancer
2001;91:1201–12. BerghP,KindblomLG,GunterbergB,RemottiF,RydW,Meis-KindblomJM.Prognosticfactors
inchordomaofthesacrumandmobilespine:astudyof39patients.Cancer2000;88:2122–34. BullardDunnK.Retrorectaltumors.SurgClinNAm2010;90:163–71. CasaliPG,MessinaA,StacchiottiS,etal.Imatinibmesylateinchordoma.Cancer
2004;101(9):2086–97. CasaliPG,StacchiottiS,SangalliC,OlmiP,GronchiA.Chordoma.CurrOpinOncol
2007;19(4):367–70. DozoisEJ,JacofskyDJ,DozoisRR.Presacraltumors.In:WolffBG,FleshmanJW,BeckDE,eds.
TheASCRSTextbookofColonandRectalSurgery.NewYork,NY:Springer,2007:501–14.
p.182
p.183
DozoisEJ,MalireddyKK,BowerTC,StansonAW,SimFH.Managementofaretrorectal
Lipomatoushemangiopericytomabypreoperativevascularembolizationandmultidisciplinary
surgicalteam:reportofacase.DisColonRectum2009;52(5):1017–20. FongSS,CoddR,SagarPM.Laparoscopicexcisionofretrorectaltumours.ColorectalDis
2014;16(11):O400–3. FreierDT,StanleyJC,ThompsonN.Retrorectaltumorsinadults.SurgGynecolObstet
1971;132(4):681–6. FuchsB,YaszemskiMJ,SimFH.Combinedposteriorpelvisandlumbarspineresectionfor
sarcoma.ClinOrthop2002;397:12–18. GalliaGL,HaqueR,GaronzikI,etal.Spinalpelvicreconstructionaftertotalsacrectomyforen
blocresectionofgiantsacralchordoma.JNeurosurgSpine2005;3:501–6. GlasgowSC,BirnbaumEH,LowneyJK,etal.Retrorectaltumors:adiagnosticandtherapeutic
challenge.DisColonRectum2005;48(8):1581–87. GraySW,SinghabhandhuB,SmithRA,SkandalakisJE.Sacrococcygealchordoma:reportofa
caseandreviewoftheliterature.Surgery1975;78:573–82. GunterbergB,KewenterJ,PetersenI,StenerB.Anorectalfunctionaftermajorresectionofthe
sacrumwithbilateralorunilateralsacrificeofsacralnerves.BrJSurg1976;63:546–54. GunterbergB,RomanusB,StenerB.Pelvicstrengthaftermajoramputationofthesacrum:an
experimentalstudy.ActaOrthopScand1976;47:635–42. HobsonKG,GhaemmaghamiV,RoeJP,GoodnightJE,KhatriVP.Tumorsoftheretrorectal
space.DisColonRectum2005;48(10):1964–74. HofH,WelzelT,DebusJ.Effectivenessofcetuximab/gefitinibinthetherapyofasacral
chordoma.Onkologie2006;29(12):572–74. Hosseini-NikH,HosseinzadehK,BhayanaR,JhaveriKS.MRimagingoftheretrorectal-presacral
tumors:analgorithmicapproach.AbdomImaging2015;40:2630–44. HsiehPC,XuR,SciubbaDM,etal.Long-termclinicaloutcomesfollowingenblocresectionsfor
sacralchordomasandchondrosarcomas:aseriesoftwentyconsecutivepatients.Spine
2009;34(20):2233–9. IsikN,ElmaciI,GokbenB,BalakN,TosyaliN.Currarinotriad:surgicalmanagementandfollow
upresultsoffourcases.PediatrNeurosurg2010;46(2):110–9. JaoSW,BeartRWJr,SpencerRJ,ReimanHM,IlstrupDM.Retrorectaltumors.MayoClinic
experience,1960–1979.DisColonRectum1985;28:644–52. KaiserTE,PritchardDJ,UnniKK.Clinicopathologicstudyofsacrococcygealchordoma.Cancer
1984;53:2574–8. McMasterML,GoldsteinAM,BromleyCM,etal.Chordoma:incidenceandsurvivalpatternsin
theUnitedStates,1973–1995.CancerCausesControl2001;12(1):331–46. MercheaA,LarsonDW,HubnerM,WengerDE,RosePS,DozoisEJ.Thevalueofpreoperative
biopsyinthemanagementofsolidpresacraltumors.DisColonRectum2013;56:756–60. MessickCA,HullT,RosselliG,KiranRP.Lesionsoriginatingwithintheretrorectalspace:a
diversegrouprequiringindividualizedevaluationandsurgery.JGastrointestSurg
2013;17:2143–52. NedelcuM,AndreicaA,SkalliM,etal.Laparoscopicapproachforretrorectaltumors.Surg
Endosc2013;27(11):4177–83. NewmanCB,KeshavarziS,AryanHE.Enblocsacrectomyandreconstruction:technique
modificationforpelvicstabilization.SurgNeurol2009;72:752–6. OhJK,YangMS,YoondoH,etal.Roboticresectionofhugepresacraltumors:caseseriesand
comparisonwithanopenresection.JSpinalDisordTech2014;27(4):E151–4. OrenM,LorberB,LeeSH,TruexRCJr,GennaroAR.Anteriorsacralmeningocele:reportoffive
casesandreviewoftheliterature.DisColonRectum1977;20:492–505. PeterP,GeorgeU,PeacockM.Retrorectalhamartoma:a“tail”oftwocysts!IndianJRadiol
Imaging2010;20(2):129–31.doi:10.4103/0971-3026.63049. ShivnaniAT,SmallWJr,BensonA3rd,RaoS,TalamontiMS.Adenocarcinomaarisinginarectal
duplicationcyst:casereportandreviewoftheliterature.AmSurg2004;70(11):1007–9. StenerB,GunterbergB.Highamputationofthesacrumforextirpationoftumors.Principlesand
technique.Spine1978;3:351–66. StewartRJ,HumphreysWG,ParksTG.Thepresentationandmanagementofpresacraltumours.
BrJSurg1986;73:153–5. SunW,MaXJ,ZhangF,MiaoWL,WangCR,CaiZD.Surgicaltreatmentofsacralneurogenic
tumor:a10-yearexperiencewith64cases.OrthopSurg2016;8(2):162–70. UhligBE,JohnsonRL.Presacraltumorsandcystsinadults.DisColonRectum1975;18:581–9. VargaPP,BorsI,LazaryA.Sacraltumorsandmanagement.OrthopClinNorthAm
2009;40(1):105–23. WangJY,HsuCH,ChangchienCR,etal.Presacraltumor:areviewofforty-fivecases.AmSurg
1995;61:310–15. WhittakerLD,PembertonJD.Tumorsventraltothesacrum.AnnSurg1938;107:96–106. YangH,ZhuL,EbraheimNA,etal.Surgicaltreatmentofsacralchordomascombinedwithtrans
catheterarterialembolization.JSpinalDisordTech2010;23(1):47–52.
YorkJE,KaczarajA,Abi-SaidD,etal.Sacralchordoma:40-yearexperienceatamajorcancer
center.Neurosurgery1999;44:74–9;discussion9–80. ZhangH,YoshikawaK,TamuraK,etal.Carbon-11-methioninepositronemissiontomography
imagingofchordoma.SkeletalRadiol2004;33:524–30. ZhouJL,WuB,XiaoY,etal.Alaparoscopicapproachtobenignretrorectaltumors.Tech
Coloproctol2014;18(9):825–33.
PARTVIII
LOCALEXCISIONOFRECTAL CARCINOMA
Chapter24
StandardTransanal
StevenR.Hunt

INDICATIONS/CONTRAINDICATIONS

Transanalexcisionisappropriateforadenomas,carcinoids,and favorableearly-stagerectalcancerswithin8cmoftheanalverge. Althoughitissometimespossibletoremovetumorshigherthan8cm withthistechnique,alternativemeansshouldbeconsidered,suchas transanalendoscopicsurgeryoralowanteriorresectionoftherectum.
Onlythemostfavorableadenocarcinomasshouldbeconsideredfor transanalexcision.Favorablecharacteristicsincludethefollowing:
Size<4cm Freelymobile Welltomoderatedifferentiation Nolymphovascularinvasion UltrasoundT1 UltrasoundN0
Mucinousandsignet-cellpathologiesarerelativecontraindicationsfor transanalexcisionbecausetheyhaveahighriskofrecurrence.
Ifapatienthascomorbidconditionsthatwouldprecluderadical surgery,less-favorabletumorscanbetransanallyexcised.Insuchcases, patientsmaybenefitfromneoadjuvantoradjuvantradiationtosterilize thelymphatics.
PREOPERATIVEPLANNING
Beforeperformingatransanalexcision,thetumorshouldbecarefully evaluatedtoconfirmthatitisamenabletolocaltreatment.Examination intheofficeshouldconsistofacarefuldigitalrectalexaminationto determinethelocationofthetumoranditsmobility.Theexamination shouldalsoincludeanoscopyorrigidproctoscopytodeterminethe distanceofthetumorfromtheanalvergeandtoassessthefeasibilityof transanalexcision.Thelateralityandanterior–posteriorlocalizationof thetumorisimportantinthepositioningofthepatientsforthe procedure.Atransrectalultrasoundormagneticresonanceimaging shouldbeperformedtostagethetumor.Althoughitisoftendifficultto differentiatebetweenanadenomaandasuperficialT1tumoron ultrasound,itisimportanttoexcludeadeeperinvasionbecausemore advancedtumorsshouldbemanagedwithproctectomyinmedicallyfit patients.Allbiopsyresultsofanytumorsthatareconsideredforlocal excisionshouldbecarefullyreviewed.Iftransanalexcisionistobe performedforcancer,astagingassessmentconsistingofaCTscan, (chest/abdomen/pelvis)CEA,andcompletecolonoscopyshouldbedone.
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p.186
Itistheauthors’practicetoprepareeachpatientwithasodium phosphateenemaonthedayofthesurgery.Theauthorsdonotroutinely useantibioticordeepvenousthrombosis(DVT)prophylaxisatthetime ofthesurgery.

SURGERY

ClinicalAnatomy
Therelevantanatomyfortransanalexcisionconsistsoftheanalcanaland rectumwithin10cmoftheanalverge,becausemoreproximaltumorsare verydifficulttoremovebyconventionaltransanaltechniques.Important anatomicallandmarksincludetheanalverge,whichisthedistalendof theanalcanalwiththebuttockseffaced.Thedentatelineisavisible irregularlinethatseparatesthecolumnarepitheliumoftherectumfrom thestratifiedepitheliumoftheanalcanalwhoselocationwithintheanal canalisvariable.Theanalcanalreferstotheareafromtheanalvergeto thetopoftheanalsphinctercomplex.Theupperedgeoftheanalcanalis definedbytheanorectalring.Abovetheanorectalring,therectum becomesmuchmorecapacious.Theanalcanalisofvaryinglength dependingonthehabitusofthepatientandcanvaryinlengthfrom2to4 cm.Themuscularispropriaoftherectumconsistsofaninnerlayerof circularsmoothmusclefibersandanouterlayeroflongitudinalsmooth musclefibers.Theinternalanalsphincterisanextensionofthecircular smoothmuscleoftherectum.Thedistalendoftheinternalanal sphincterispalpableattheanalvergeanddefinestheinneraspectofthe intersphinctericplane.
Posteriorlyandlaterally,themesorectalfatsurroundstherectum.In women,thevaginaisimmediatelyanteriortothemuscularispropria abovetheanalcanal.Inmen,theprostateglandandseminalvesiclesare encounteredanteriorlyabovetheanalverge.Theanteriorperitoneal reflexionvariesbetweenmenandwomenandcanvaryaccordingtothe habitusofthepatient.Ingeneral,theanteriorperitonealreflexionlies somewherebetween6and9cmabovetheanalvergeanteriorlyand anterolaterallytotherectum.
Positioning
Patientpositioningisdependentonthelocationofthelesion.Anterior andlaterallesionsarebestapproachedwithpatientsintheprone jackknifeposition.Thepatient’sbuttocksshouldbelaterallyretracted withtapetoeffacetheanus(Fig.24-1).Patientswithposteriorlesions maybeplacedinthedorsallithotomypositionwiththebuttockstaped apart.
FIGURE24-1Withthepatientinthepronejackknife
position,thebuttocksaretapedaparttoeffacetheanus.
Technique
Thechoiceofanesthesiaisdependentonsurgeonpreferencebecauseitis possibletoperformalocalexcisionunderMAC/local,spinal,orgeneral anesthesia.TheanusiseffacedwithaLonestarretractor(Fig.24-2). Visualizationisbestaccomplishedwithalightedanoscope.Itmaybe necessarytoplacestaysuturesatthelateralmarginsofhighertumorsto providetractionanddeliverthetumorintoview.Thetumoritselfshould notbehandledwithinstruments.Thedefaultprocedureshouldbeafull­thicknessexcision,unlessthetumorisassuredlybenign,inwhichcasea submucosalexcisionisacceptable.
FIGURE24-2TheLonestarretractor(CooperSurgical,
Trumbull,CT)isusedtofurthereffacetheanusandprovide betterexposure.Thehooksoftheretractorareplacedatthe dentateline.
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A1-cmmarginisscoredaroundthetumorwiththecautery.Inscoring themargin,itisnecessarytocreateacharratherthanmereblanchingof themucosabecausevisualizationofthismargininthelatterportionsof theprocedurecanbecomedifficultduetoblood.Afterthemarginshave beencircumferentiallyscored,thefull-thicknessexcisionshouldbegin.It iseasiesttostarttheexcisionatthedistalmarginofthetumor.During thisincision,theoperatorshouldtakenoteofeachlayerbecauseitis crossedincludingthesubmucosa,themuscularislayer,andtheexposure oftheperirectalfat.Theremaybeapaucityofperirectalfatarounddistal lesions,andthelevatormusclesmaybecomeimmediatelyvisibleonfull incisionofthemuscularispropria.Anteriorly,thereisalsoscant mesorectalfat,andthevaginaorDenonvilliers’fasciaoftheprostatemay beimmediatelyencounteredafterincisingthroughtherectalwall.
Afterafull-thicknessincisionhasbeenmade,theincisionshouldbe laterallyextendedaroundthetumor.PlacinganAllis–AdairBabcock clamporsuturesonthemarginsofthespecimenfacilitatesvisualization (Fig.24-3).Dissectioninthemesorectalfatshouldthencommence underneaththetumortoleaveawidemarginofmesorectalfatonthe specimen.Finally,theremainingsuperiorrectalwallisdivided.Although weusetheelectrocauteryforthemajorityofourdissection,vessel-sealing
devicescanalsobeusedtoobtainhemostasisduringthedissection.
FIGURE24-3AnAllisclampisusedtograsptheedgeof
thepolypduringexcision,whereaslateralstaysuturesare usedtoprovidebetterexposureduringthedissectionofthe upperbordersofthepolyp.
Oncethetumorhasbeenexcised,itshouldberemovedandoriented forthepathologistsbysuturingorpinningittoaboard.Thedefect shouldbeinspectedandirrigatedwithsaline,andmeticuloushemostasis shouldbeobtainedwithelectrocautery(Fig.24-4).
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