e391
Diseases of the Colon & Rectum Volume 58: 6 (2015)
were diagnosed with pulmonary metastasis, 9 of which were T3 or T4 tumors.4 Differences in the literature may be explained by the collation of colon and rectal cancers in data sets. However, the overall low incidence of pulmonary metastases in CRC remains the primary difference. In keeping with this, many studies examining the relationship between clinicopathologic features and the development of pulmonary metastases are limited in terms of cohort size. The effect is to increase the possibility of type I and II statistical errors (particularly common in binary classification and small cohort studies). Such limitations could be overcome by using a multi-institutional collaborative approach aimed at determining the true association between clinicopathologic features such as T stage and the development of pulmonary metastasis. The recent investigation of neoadjuvant chemotherapy in the setting of colon cancer further increases the need for accurate correlation between stage and likelihood of developing pulmonary spread. Recent clarifications of mesenteric anatomy and radiologic correlates are likely to further enhance our ability to preoperatively differentiate clinicopathologic features of colon cancer (similar to what occurred for rectal cancer).5–7 In keeping with this, a large-scale multicenter study should be undertaken to accurately determine the association among varying stages of early and advanced colon cancer and the development of pulmonary metastases in general. REFERENCES 1. Hogan J, O’Rourke C, Duff G, et al. Preoperative staging CT thorax in patients with colorectal cancer: its clinical importance. Dis Colon Rectum. 2014;57:1260–1266. 2. Ullah et al. Dis Colon Rectum. 2015;58:e390. 3. Kanzaki R, Higashiyama M, Oda K, et al. Outcome of surgical resection for recurrent pulmonary metastasis from colorectal carcinoma. Am J Surg. 2011;202:419–426. 4. Kirke R, Rajesh A, Verma R, Bankart MJ. Rectal cancer: incidence of pulmonary metastases on thoracic CT and correlation with T staging. J Comput Assist Tomogr. 2007;31:569–571. 5. Culligan K, JC Coffey, Kiran RP, Kalady M, Lavery IC, Remzi FH. The mesocolon: a prospective observational study. Colorectal Dis. 2012:14:41–48. 6. Culligan K, Walsh S, Dunne C, et al. The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg. 2014;260:1048–1056. 7. Coffey JC, Sehgal R, Culligan K, et al. Terminology and nomenclature in colonic surgery: universal application of a rule-based approach derived from updates on mesenteric anatomy. Tech Coloproctol. 2014;18:789–794.
John Hogan, M.D. John C. Coffey, M.D., Ph.D., F.R.C.S. Limerick, Ireland
The Pelvic Floor Debates To the Editor—I read with great interest and delight about the recent debates on ventral mesh rectopexy by Brown et al1 in the December 2014 issue of Diseases of the Colon & Rectum. As one of the coauthors of an article2 on the use of polypropylene mesh in pelvic floor repair (named total pelvic mesh repair (TPMR)), I welcome this debate to advance the understanding of the functional changes in defecation with rectal and other pelvic organ prolapse. Epidemiologic studies correlating pelvic organ prolapse with symptoms have clearly shown a correlation of anal incontinence, rectal prolapse, defecation dysfunction, constipation, and vaginal bulging with stages of pelvic floor prolapse.3 Unfortunately, many of these patients endure years of suffering as a result of our failure to fully understand their disease process. Worse, these patients are often stigmatized as having anxiety, depression, obsessivecompulsive disorders, or simply as “crazies.” These views are perpetuated by some of our colleagues in presentations at our colorectal society meetings, further marginalizing their disease process as a psychosocial issue. Although psychological issues in gastrointestinal diseases are well published,4,5 they cannot fully explain the female predominance of pelvic floor prolapse or the high prevalence rate of 23.7%.6 Olsen et al7 reported that 11% of women required pelvic floor-related surgery by the age of 80 years, with a reoperation rate of 30%. It is estimated that by 2050, the proportion of elderly in the United States over the age of 75 years will increase from our current 6% to 11%.8 The number of American women with at least one pelvic floor-related disorder will increase from 28.1 million in 2010 to 43.8 million by 2050, with 28.4 million with urinary incontinence, 16.8 million with fecal incontinence and 4.9 million with organ prolapse.9 The difficulties of mastering the understanding of pelvic floor prolapse are not only because we have yet to fully understand the disease process but also because our array of surgical techniques to fix the prolapse far exceeds our understanding of what exactly are we trying to fix. Fortunately, Brown et al1 very succinctly explained the rationale for placement of the mesh in the rectovaginal plane to support pelvic organ prolapse and their surgical experience with such a technique. This is similar to our experience and understanding of the importance of mesh in the rectovaginal plane and its role in narrowing the levator hiatus, securing the perineum/perineal body and providing the lattice of support of the pelvic organs and their realignment for proper function.10 Brown et al1 point out the various techniques of pelvic organ repair that illustrate our failure to understand the disease process and point out the remarkable results of the laparoscopic ventral rectopexy technique of placing the mesh in the rectovaginal plane, as described by D’Hoore et al.11 Unfortunately, the
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
e392
techniques of D’Hoore et al11 and Sullivan et al2 have not been studied in a randomized fashion to be an established technique of choice. The technique of ventral rectopexy described by D’Hoore et al11 differs from the TPMR technique described by Sullivan et al2 in several important aspects. In the TPMR, the placement of the polypropylene mesh is deep in the rectovaginal plane to the level of the introitus to secure the perineal body. Second, the mesh is placed to the left of the mesorectum to use the curvature of the rectum to lessen the exposure of the mesh to the small bowel. Third, the mesh is secured at the level of S1 to S2 and not in the promontory, as shown in the technique by D’Hoore et al.11 Fourth, the rectum is dissected free from the posterior pelvic floor to help elevate the rectum and allow the mesh to sit in a tension-free manner to the left side and behind the rectum as it attaches to the S1 to S2. Fifth, 2 additional strips of mesh are secured to the main sacroperineal mesh to help support the lateral wall of the vagina and bladder. The TPMR has been performed in more than 422 patients from 1990 to 2013, and in 2001 we reported our first 10-year experience.2 We showed a mesh-related complication rate of 10% (mesh erosion, bowel obstruction, bleeding, pelvic pain, and constipation). However, mesh erosion complications constituted
Diseases of the Colon & Rectum Volume 58: 6 (2015)
were diagnosed with pulmonary metastasis, 9 of which were T3 or T4 tumors.4 Differences in the literature may be explained by the collation of colon and rectal cancers in data sets. However, the overall low incidence of pulmonary metastases in CRC remains the primary difference. In keeping with this, many studies examining the relationship between clinicopathologic features and the development of pulmonary metastases are limited in terms of cohort size. The effect is to increase the possibility of type I and II statistical errors (particularly common in binary classification and small cohort studies). Such limitations could be overcome by using a multi-institutional collaborative approach aimed at determining the true association between clinicopathologic features such as T stage and the development of pulmonary metastasis. The recent investigation of neoadjuvant chemotherapy in the setting of colon cancer further increases the need for accurate correlation between stage and likelihood of developing pulmonary spread. Recent clarifications of mesenteric anatomy and radiologic correlates are likely to further enhance our ability to preoperatively differentiate clinicopathologic features of colon cancer (similar to what occurred for rectal cancer).5–7 In keeping with this, a large-scale multicenter study should be undertaken to accurately determine the association among varying stages of early and advanced colon cancer and the development of pulmonary metastases in general. REFERENCES 1. Hogan J, O’Rourke C, Duff G, et al. Preoperative staging CT thorax in patients with colorectal cancer: its clinical importance. Dis Colon Rectum. 2014;57:1260–1266. 2. Ullah et al. Dis Colon Rectum. 2015;58:e390. 3. Kanzaki R, Higashiyama M, Oda K, et al. Outcome of surgical resection for recurrent pulmonary metastasis from colorectal carcinoma. Am J Surg. 2011;202:419–426. 4. Kirke R, Rajesh A, Verma R, Bankart MJ. Rectal cancer: incidence of pulmonary metastases on thoracic CT and correlation with T staging. J Comput Assist Tomogr. 2007;31:569–571. 5. Culligan K, JC Coffey, Kiran RP, Kalady M, Lavery IC, Remzi FH. The mesocolon: a prospective observational study. Colorectal Dis. 2012:14:41–48. 6. Culligan K, Walsh S, Dunne C, et al. The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg. 2014;260:1048–1056. 7. Coffey JC, Sehgal R, Culligan K, et al. Terminology and nomenclature in colonic surgery: universal application of a rule-based approach derived from updates on mesenteric anatomy. Tech Coloproctol. 2014;18:789–794.
John Hogan, M.D. John C. Coffey, M.D., Ph.D., F.R.C.S. Limerick, Ireland
The Pelvic Floor Debates To the Editor—I read with great interest and delight about the recent debates on ventral mesh rectopexy by Brown et al1 in the December 2014 issue of Diseases of the Colon & Rectum. As one of the coauthors of an article2 on the use of polypropylene mesh in pelvic floor repair (named total pelvic mesh repair (TPMR)), I welcome this debate to advance the understanding of the functional changes in defecation with rectal and other pelvic organ prolapse. Epidemiologic studies correlating pelvic organ prolapse with symptoms have clearly shown a correlation of anal incontinence, rectal prolapse, defecation dysfunction, constipation, and vaginal bulging with stages of pelvic floor prolapse.3 Unfortunately, many of these patients endure years of suffering as a result of our failure to fully understand their disease process. Worse, these patients are often stigmatized as having anxiety, depression, obsessivecompulsive disorders, or simply as “crazies.” These views are perpetuated by some of our colleagues in presentations at our colorectal society meetings, further marginalizing their disease process as a psychosocial issue. Although psychological issues in gastrointestinal diseases are well published,4,5 they cannot fully explain the female predominance of pelvic floor prolapse or the high prevalence rate of 23.7%.6 Olsen et al7 reported that 11% of women required pelvic floor-related surgery by the age of 80 years, with a reoperation rate of 30%. It is estimated that by 2050, the proportion of elderly in the United States over the age of 75 years will increase from our current 6% to 11%.8 The number of American women with at least one pelvic floor-related disorder will increase from 28.1 million in 2010 to 43.8 million by 2050, with 28.4 million with urinary incontinence, 16.8 million with fecal incontinence and 4.9 million with organ prolapse.9 The difficulties of mastering the understanding of pelvic floor prolapse are not only because we have yet to fully understand the disease process but also because our array of surgical techniques to fix the prolapse far exceeds our understanding of what exactly are we trying to fix. Fortunately, Brown et al1 very succinctly explained the rationale for placement of the mesh in the rectovaginal plane to support pelvic organ prolapse and their surgical experience with such a technique. This is similar to our experience and understanding of the importance of mesh in the rectovaginal plane and its role in narrowing the levator hiatus, securing the perineum/perineal body and providing the lattice of support of the pelvic organs and their realignment for proper function.10 Brown et al1 point out the various techniques of pelvic organ repair that illustrate our failure to understand the disease process and point out the remarkable results of the laparoscopic ventral rectopexy technique of placing the mesh in the rectovaginal plane, as described by D’Hoore et al.11 Unfortunately, the
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
e392
techniques of D’Hoore et al11 and Sullivan et al2 have not been studied in a randomized fashion to be an established technique of choice. The technique of ventral rectopexy described by D’Hoore et al11 differs from the TPMR technique described by Sullivan et al2 in several important aspects. In the TPMR, the placement of the polypropylene mesh is deep in the rectovaginal plane to the level of the introitus to secure the perineal body. Second, the mesh is placed to the left of the mesorectum to use the curvature of the rectum to lessen the exposure of the mesh to the small bowel. Third, the mesh is secured at the level of S1 to S2 and not in the promontory, as shown in the technique by D’Hoore et al.11 Fourth, the rectum is dissected free from the posterior pelvic floor to help elevate the rectum and allow the mesh to sit in a tension-free manner to the left side and behind the rectum as it attaches to the S1 to S2. Fifth, 2 additional strips of mesh are secured to the main sacroperineal mesh to help support the lateral wall of the vagina and bladder. The TPMR has been performed in more than 422 patients from 1990 to 2013, and in 2001 we reported our first 10-year experience.2 We showed a mesh-related complication rate of 10% (mesh erosion, bowel obstruction, bleeding, pelvic pain, and constipation). However, mesh erosion complications constituted
![[The spastic pelvic floor syndrome].](/assets/img/hold.png)
