Can you orient a rectum?

[RenalMan]

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I'm not talking about proximal/distal.

One of my attendings wants us to orient rectal tumors anterior/posterior/left/right (or at least report where our sections come from). When I approached this idea to another attending he seemed to think it was ludicrous because he claimed it was impossible to orient a rectum.

I, indeed, have observed that the surgical margin looks a little different circumferentially around the distal portion and I think one of our PAs claimed this portion is key to orienting it.

I was somewhat surprised that something that seems fairly important would be disagreed upon by attendings, so rather than saying "Dr. ____ said that's ludicrous and impossible, Dr. ____," I figure I'll ask you all.

 

[Patho2009]

For rectal carcinoma, the radial margin is more critical than the location of the tumor (post, ant, lat...etc), as your attending asked (I am afraid you misunderstood him/her).

Below is what you need to know ( a copy and paste from Washu Surg Path manual) . Make sure you understand it and know how to do it grossly:

The radial resection margin may be the single most critical factor in predicting local recurrence, particularly for rectal carcinoma. It is the nonperitonealized surface including the perirectal soft tissue (adventitia) and the mesenteric pedicle. The radial margin should be inked before lymph node dissection is performed. A common mistake is to consider serosal surface as radial margin; a T3 tumor can have an involved radial margin (incomplete resection), and a T4 tumor (positive serosal surface) can have an uninvolved radial margin (complete resection).

 

[Sean2tall]

Well, on an ideal specimen the peritonealized surface should extend more distally on the anterior surface and the roughened resection margin would extend more proximally on the posterior. Of course, that may not always be visible. There is a picture in this paper:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[RenalMan]

Well, on an ideal specimen the peritonealized surface should extend more distally on the anterior surface and the roughened resection margin would extend more proximally on the posterior. Of course, that may not always be visible. There is a picture in this paper:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

this sounds right -- thanks for the link!

 

[green mantis]

You never know, orienting in a proximal to distal sense may be challenging to some residents. I once had a junior resident ask me how to orient an amputed finger for melanoma.

During my SP fellowship, I had to go to the OR to pick up colorectal specimens. They usually wanted pathology to open the specimen in the room, so they could see the relationship between the tumor & the distal margin. If you weren't sure, you just asked the surgeons to orient the specimen for you. It beats comparing which side has more peritonealized surface, something we commonly do on uteri.

If you do ask the surgeons, make sure you document in your gross "the specimen is oriented by the surgeon".


----- Antony

 

[schrute]

Helpful TME protocol with pictures.

View attachment Parfitt_and_Driman_2007_Evaluation_of_TME.pdf