Sigmoid, Sigmoid Colon, Neoplasm, Cancer Clinical Trial
Official title:
Surgical Anatomy and 'Waisting' of the sIgmoid SpEcimen
Treatment of rectal cancer has improved to the extent that its local recurrence rates are now much lower than other sites in the large bowel. It has been found that higher rates of recurrence in the sigmoid section of the colon, just before the rectum. This might be due to a narrowing in the bowel, and difficulties identifying whether cancers are in the sigmoid or rectum. The aim is to investigate the bowel from 20 patients undergoing surgery for left sided colorectal cancer at the Royal Marsden. These patients would have routine investigations and treatments, but once the bowel has been removed, it would undergo a MRI scan and additional slices and photography during pathological analysis.
Following surgery for a primary cancer (ie has not spread), the patient may still die from
the cancer. This may be due to local or distant recurrence. Local recurrence will be near the
site of the surgery; for bowel cancer, this may be at the site of the joined bowel or nearby
in the abdomen. Distant recurrence will be elsewhere in the body.
Local recurrence is much more likely when there is incomplete removal of all the cancer cells
at the time of surgery This can occur if the surrounding tissue, such as the bowel mesentery,
is not completely removed. The bowel mesentery is the fatty tissue in which blood vessels and
lymph nodes travel up to the bowel. During research into rectal cancer, it was established
that there was a rectal mesentery "waist" or narrowing that made it difficult with
conventional surgery to remove all the cancer cells. A modified operation gave much better
cancer clearance.
Rectal cancer outcomes are now superior to other sites of large bowel cancer. Data from the
Royal Marsden and elsewhere show that local recurrence rates of the sigmoid colon are
approximately double that of the rectum. This may be due to 2 potential issues: a sigmoid
waist, and difficulties in differentiating rectal and sigmoid cancers.
This recurrence may be due to the presence of a waist in the sigmoid mesentery. A case series
from Leeds has shown initial data suggesting there is a significantly smaller area in this
area. However, this study was underpowered and not conducted prospectively in a
scientifically rigorous manner. If a waist was present that could prevent cancer being
successfully removed, then an extended operation could be performed or
radiotherapy/chemotherapy given before the operation to shrink the cancer.
The sigmoid colon is the section of bowel before the rectum. They can be differentiated by
examining the bowel during or after the operation for specific landmarks (taenia coli,
appendices epiploicae) that are present on the sigmoid but not on the rectum. However, these
landmarks cannot be seen on a patient's pre-operative scans, making it is very difficult to
tell whether a cancer is in the sigmoid or the rectum. At our institution, we use MRI to
define the end of the sigmoid at MRI as the transition point from the sigmoid mesocolon to
the mesorectal apex. This can be seen on sagittal views between the fanning branches of the
sigmoid artery proximally and the superior rectal vein distally. On axial views, it can be
seen when the rectum fixed posteriorly by the mesorectum transitions into the sigmoid hanging
freely on the sigmoid mesocolon. If the distance from the anterior peritoneal reflection to
the mesorectal apex on MRI or the coalescence of the taenia coli on histology correlate, it
can be predicted pre-operatively on MRI whether a patient's cancer is in the sigmoid or the
rectum, and what kind of treatment they should undergo.
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