Rectal eversion for direct access to the distal resection margin: do we need another tool in the toolbox of rectal cance
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EDITORIAL
Rectal eversion for direct access to the distal resection margin: do we need another tool in the toolbox of rectal cancer surgery? R. O. Perez1,2,3,4 · G. P. São Julião1,3,4 Received: 7 July 2020 / Accepted: 8 July 2020 © Springer Nature Switzerland AG 2020
Rectal cancer below the peritoneal reflection is currently one of the most challenging diseases in colorectal surgery. Advances in contemporary imaging, complexities of multimodality approaches and a variety of surgical and even non-surgical alternatives have all led to improvements in local disease control, sphincter and organ preservation and more recently, even in survival [1–6]. Colorectal surgeons in particular, now have plenty of tools to choose from to provide the pathologist with the perfect total mesorectal excision (TME) specimen and patients with an optimal outcome. Perfection here would include an intact TME envelope, sufficient radial and distal margins coupled to optimal anorectal function. In the present issue of Techniques in Coloproctology, Sun et al. [7] describe the oncological and functional outcomes with a procedure popular in eastern countries but not frequently mentioned in western surgical textbooks. After full mobilization of the rectum and TME, transection of the sigmoid allows for the eversion of the rectum through the anus, allowing for tailored determination of the distal resection margin performed under direct vision without the need for the use of fancy endoscopic technology or instrumentation. At a first glance, this variation of the standard intersphincteric resection seems to result in excellent postoperative functional and oncological outcomes. In this setting, one would expect to immediately add this approach to the long list of surgical procedures to be taught and performed to our rectal cancer patients, particularly to the ones located at or very close to the anorectal junction.
* R. O. Perez [email protected] 1
Angelita and Joaquim Gama Institute, São Paulo, Brazil
2
São Paulo Branch, Ludwig Institute for Cancer Research, São Paulo, Brazil
3
Departamento de Cirurgia Oncológica, Hospital Beneficencia Portuguesa, São Paulo, Brazil
4
Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
However, a few unanswered questions should at least restrain the most excited reader prior to full implementation of this technique in clinical practice. First, this technique has not yet been tested against any of the other available techniques. The lack of a control group in Sun’s study is clearly a significant limitation here. Second, the absence of a clear denominator is also an important limitation. It becomes almost impossible to understand the characteristics of the ideal candidates for this procedure without knowing the exact differences between them and the patients that underwent other surgical alternatives. Ultimately, several prerequisites need to be met prior to attempting rectal eversion. The mesorectum cannot be bulky since its passage through the rectum and anus may be impossible or lead to its dis
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