Localization of the peritoneal reflection in the pelvis by endorectal ultrasound

Abstract

Background: Large adenomas and low-risk rectal carcinomas (T₁) that are localized distal of the pelvic peritoneal reflection (PPR) are treated by transanal excision. However, the location of the PPR varies widely and cannot be detected reliably by preoperative methods. Therefore, we evaluated the value of endorectal ultrasound (EUS) for the prediction of an intraperitoneal location of rectal tumors.

Methods: Fourteen patients with rectal tumors measuring ≤15 cm from the anal verge were examined by EUS. If peristalsis beyond the rectal wall or any intraperitoneal fluid was seen at the proximal tumor edge, the lesion was classified as localized above or in the level of the PPR. During the operation, the surgeon determined whether the upper end of the tumor reached the PPR.

Results: In each of our 14 patients, the prediction by EUS was correct. In two patients, a small rectal tumor was excised with an electric sling during rectoscopy, but the polyp bases were not free of dysplastic epithelial tissue. The point where these two polyps were removed could be visualized by endoscopy but not by EUS. Once the relevant area was marked with a titanic endoclip, EUS was able to predict the resection place in relation to the PPR in these two patients as well.

Conclusions: Although this knowledge would be very important for the therapeutic strategy of small rectal tumors, it is impossible to determine the location of a rectal tumor with regard to the PPR either clinically or by endoscopy. EUS provides this information with high reliability. Thus, we recommend EUS as the method of choice for predicting the location of the PPR.