ﺍﻮﹸﻟﺎﹶﻗ
ﻚﻧﺎﺤﺒﺳ
ﺎﹶﻟ
ﻢﹾﻠﻋ
ﺎﻨﹶﻟ
ﺎﱠﻟﹺﺇ
ﺎﻣ
ﺎﻨﺘﻤﱠﻠﻋ
ﻚﻧﹺﺇ
ﺖﻧﹶﺃ
ﻢﻴﻠﻌﹾﻟﺍ
ﻢﻴﻜﺤﹾﻟﺍ
)
32
(
ﻪّﻣﹸﺃ ﻪﺘﹶﻠﻤﺣ ﻪﻳﺪﻟﺍﻮﹺﺑ ﹶﻥﺎﺴﻧﹺﺈﹾﻟﺍ ﺎﻨﻴّﺻﻭﻭ
ﻲﻟ ﺮﹸﻜﺷﺍ ﻥﹶﺃ ﹺﻦﻴﻣﺎﻋ ﻲﻓ ﻪﹸﻟﺎﺼﻓﻭ ﹴﻦﻫﻭ ﻰﹶﻠﻋ ﺎﻨﻫﻭ
ﺮﻴﺼﻤﹾﻟﺍ ّﻲﹶﻟﹺﺇ ﻚﻳﺪﻟﺍﻮﻟﻭ
)
14
(
MOHAMMED V DE RABAT
FACULTE DE MEDECINE ET DE PHARMACIE - RABAT
DOYENS HONORAIRES :
1962 – 1969 : Professeur Abdelmalek FARAJ 1969 – 1974 : Professeur Abdellatif BERBICH 1974 – 1981 : Professeur Bachir LAZRAK 1981 – 1989 : Professeur Taieb CHKILI
1989 – 1997 : Professeur Mohamed Tahar ALAOUI 1997 – 2003 : Professeur Abdelmajid BELMAHI 2003 - 2013 : Professeur Najia HAJJAJ – HASSOUNI ADMINISTRATION :
Doyen
Professeur Mohamed ADNAOUI
Vice-Doyen chargé des Affaires Académiques et estudiantines
Professeur Brahim LEKEHAL
Vice-Doyen chargé de la Recherche et de la Coopération
Professeur Toufiq DAKKA
Vice-Doyen chargé des Affaires Spécifiques à la Pharmacie
Professeur Jamal TAOUFIK
Secrétaire Général
1 - ENSEIGNANTS-CHERCHEURS MEDECINS ET PHARMACIENS
PROFESSEURS :
DECEMBRE 1984
Pr. MAAOUNI Abdelaziz Médecine Interne – Clinique Royale
Pr. MAAZOUZI Ahmed Wajdi Anesthésie -Réanimation
Pr. SETTAF Abdellatif Pathologie Chirurgicale
NOVEMBRE ET DECEMBRE 1985
Pr. BENSAID Younes Pathologie Chirurgicale
JANVIER, FEVRIER ET DECEMBRE 1987
Pr. LACHKAR Hassan Médecine Interne
Pr. YAHYAOUI Mohamed Neurologie
DECEMBRE 1989
Pr. ADNAOUI Mohamed Médecine Interne –Doyen de la FMPR
Pr. OUAZZANI Taïbi Mohamed Réda Neurologie
JANVIER ET NOVEMBRE 1990
Pr. HACHIM Mohammed* Médecine-Interne
Pr. KHARBACH Aîcha Gynécologie -Obstétrique
Pr. TAZI Saoud Anas Anesthésie Réanimation
FEVRIER AVRIL JUILLET ET DECEMBRE 1991 Pr. AZZOUZI Abderrahim Anesthésie Réanimation- Doyen de FMPO
Pr. BAYAHIA Rabéa Néphrologie
Pr. BELKOUCHI Abdelkader Chirurgie Générale
Pr. BENCHEKROUN Belabbes Abdellatif Chirurgie Générale
Pr. BENSOUDA Yahia Pharmacie galénique
Pr. BERRAHO Amina Ophtalmologie
Pr. BEZAD Rachid Gynécologie Obstétrique Méd. Chef Maternité des
Orangers
Pr. CHERRAH Yahia Pharmacologie
Pr. CHOKAIRI Omar Histologie Embryologie
Pr. KHATTAB Mohamed Pédiatrie
Pr. SOULAYMANI Rachida Pharmacologie- Dir. du Centre National PV Rabat Pr. TAOUFIK Jamal
Chimie thérapeutique V.D à la pharmacie+Dir. du CEDOC
+
Directeur du Médicament
DECEMBRE 1992
Pr. AHALLAT Mohamed Chirurgie Générale Doyen de FMPT
Pr. BENSOUDA Adil Anesthésie Réanimation
Pr. CHAHED OUAZZANI Laaziza Gastro-Entérologie
Pr. EL OUAHABI Abdessamad Neurochirurgie
Pr. FELLAT Rokaya Cardiologie
Pr. GHAFIR Driss* Médecine Interne
Pr. JIDDANE Mohamed Anatomie
Pr. TAGHY Ahmed Chirurgie Générale
Pr. ZOUHDI Mimoun Microbiologie
MARS 1994
Pr. BENJAAFAR Noureddine Radiothérapie
Pr. BEN RAIS Nozha Biophysique
Pr. CAOUI Malika Biophysique
Pr. CHRAIBI Abdelmjid
Endocrinologie et Maladies Métaboliques Doyen de la
FMPA
Pr. EL AMRANI Sabah Gynécologie Obstétrique
Pr. EL BARDOUNI Ahmed Traumato-Orthopédie
Pr. EL HASSANI My Rachid Radiologie
Pr. ERROUGANI Abdelkader Chirurgie Générale – Directeur du CHIS-Rabat
Pr. ESSAKALI Malika Immunologie
Pr. ETTAYEBI Fouad Chirurgie Pédiatrique
Pr. HASSAM Badredine Dermatologie
Pr. IFRINE Lahssan Chirurgie Générale
Pr. MAHFOUD Mustapha Traumatologie – Orthopédie
Pr. RHRAB Brahim Gynécologie –Obstétrique
Pr. SENOUCI Karima Dermatologie
MARS 1994
Pr. ABBAR Mohamed* Urologie Directeur Hôpital My Ismail Meknès
Pr. ABDELHAK M’barek Chirurgie – Pédiatrique
Pr. BENTAHILA Abdelali Pédiatrie
Pr. BENYAHIA Mohammed Ali Gynécologie – Obstétrique Pr. BERRADA Mohamed Saleh Traumatologie – Orthopédie Pr. CHERKAOUI Lalla Ouafae Ophtalmologie
Pr. LAKHDAR Amina Gynécologie Obstétrique
Pr. MOUANE Nezha Pédiatrie
MARS 1995
Pr. ABOUQUAL Redouane Réanimation Médicale
Pr. AMRAOUI Mohamed Chirurgie Générale
Pr. BAIDADA Abdelaziz Gynécologie Obstétrique
Pr. BARGACH Samir Gynécologie Obstétrique
Pr. DRISSI KAMILI Med Nordine* Anesthésie Réanimation
Pr. EL MESNAOUI Abbes Chirurgie Générale
Pr. ESSAKALI HOUSSYNI Leila Oto-Rhino-Laryngologie
Pr. HDA Abdelhamid* Cardiologie Inspecteur du Service de Santé des FAR Pr. IBEN ATTYA ANDALOUSSI Ahmed Urologie
Pr. OUAZZANI CHAHDI Bahia Ophtalmologie
Pr. SEFIANI Abdelaziz Génétique
Pr. ZEGGWAGH Amine Ali Réanimation Médicale
DECEMBRE 1996
Pr. AMIL Touriya* Radiologie
Pr. BELKACEM Rachid Chirurgie Pédiatrie
Pr. BOULANOUAR Abdelkrim Ophtalmologie
Pr. EL ALAMI EL FARICHA EL Hassan Chirurgie Générale
Pr. GAOUZI Ahmed Pédiatrie
Pr. MAHFOUDI M’barek* Radiologie
Pr. OUZEDDOUN Naima Néphrologie
Pr. ZBIR EL Mehdi* Cardiologie DirecteurHôp.Mil. d’Instruction Med V Rabat
NOVEMBRE 1997
Pr. ALAMI Mohamed Hassan Gynécologie-Obstétrique
Pr. BEN SLIMANE Lounis Urologie
Pr. BIROUK Nazha Neurologie
Pr. ERREIMI Naima Pédiatrie
Pr. FELLAT Nadia Cardiologie
Pr. KADDOURI Noureddine Chirurgie Pédiatrique
Pr. KOUTANI Abdellatif Urologie
Pr. LAHLOU Mohamed Khalid Chirurgie Générale
Pr. MAHRAOUI CHAFIQ Pédiatrie
Pr. TOUFIQ Jallal Psychiatrie Directeur Hôp.Ar-razi Salé
Pr. YOUSFI MALKI Mounia Gynécologie Obstétrique
NOVEMBRE 1998
Pr. BENOMAR ALI Neurologie Doyen de la FMP Abulcassis
Pr. BOUGTAB Abdesslam Chirurgie Générale
Pr. ER RIHANI Hassan Oncologie Médicale
Pr. BENKIRANE Majid* Hématologie
JANVIER 2000
Pr. ABID Ahmed* Pneumo-phtisiologie
Pr. AIT OUAMAR Hassan Pédiatrie
Pr. BENJELLOUN Dakhama Badr.Sououd Pédiatrie
Pr. BOURKADI Jamal-Eddine Pneumo-phtisiologie Directeur Hôp. My Youssef Pr. CHARIF CHEFCHAOUNI Al Montacer Chirurgie Générale
Pr. ECHARRAB El Mahjoub Chirurgie Générale
Pr. EL FTOUH Mustapha Pneumo-phtisiologie
Pr. EL MOSTARCHID Brahim* Neurochirurgie
Pr. MAHMOUDI Abdelkrim* Anesthésie-Réanimation
Pr. TACHINANTE Rajae Anesthésie-Réanimation
Pr. TAZI MEZALEK Zoubida Médecine Interne
NOVEMBRE 2000
Pr. AIDI Saadia Neurologie
Pr. AJANA Fatima Zohra Gastro-Entérologie
Pr. BENAMR Said Chirurgie Générale
Pr. CHERTI Mohammed Cardiologie
Pr. ECH-CHERIF EL KETTANI Selma Anesthésie-Réanimation
Pr. EL HASSANI Amine Pédiatrie - Directeur Hôp.Cheikh Zaid
Pr. EL KHADER Khalid Urologie
Pr. EL MAGHRAOUI Abdellah* Rhumatologie
Pr. GHARBI Mohamed El Hassan Endocrinologie et Maladies Métaboliques
Pr. MDAGHRI ALAOUI Asmae Pédiatrie
Pr. ROUIMI Abdelhadi* Neurologie
DECEMBRE 2000
Pr.ZOHAIR ABDELLAH * ORL
Pr. BALKHI Hicham* Anesthésie-Réanimation
Pr. BENABDELJLIL Maria Neurologie
Pr. BENAMAR Loubna Néphrologie
Pr. BENAMOR Jouda Pneumo-phtisiologie
Pr. BENELBARHDADI Imane Gastro-Entérologie
Pr. BENNANI Rajae Cardiologie
Pr. BENOUACHANE Thami Pédiatrie
Pr. BEZZA Ahmed* Rhumatologie
Pr. BOUCHIKHI IDRISSI Med Larbi Anatomie
Pr. BOUMDIN El Hassane* Radiologie
Pr. CHAT Latifa Radiologie
Pr. DAALI Mustapha* Chirurgie Générale
Pr. DRISSI Sidi Mourad* Radiologie
Pr. EL HIJRI Ahmed Anesthésie-Réanimation
Pr. EL MAAQILI Moulay Rachid Neuro-Chirurgie
Pr. EL MADHI Tarik Chirurgie-Pédiatrique
Pr. EL OUNANI Mohamed Chirurgie Générale
Pr. ETTAIR Said Pédiatrie - Directeur Hôp. d’EnfantsRabat
Pr. GAZZAZ Miloudi* Neuro-Chirurgie
Pr. HRORA Abdelmalek Chirurgie Générale
Pr. KABBAJ Saad Anesthésie-Réanimation
Pr. KABIRI EL Hassane* Chirurgie Thoracique
Pr. LAMRANI Moulay Omar Traumatologie Orthopédie
Pr. LEKEHAL Brahim Chirurgie Vasculaire Périphérique
Pr. MAHASSIN Fattouma* Médecine Interne
Pr. MEDARHRI Jalil Chirurgie Générale
Pr. MOHSINE Raouf Chirurgie Générale
Pr. NOUINI Yassine Urologie - Directeur Hôpital Ibn Sina
Pr. SABBAH Farid Chirurgie Générale
Pr. SEFIANI Yasser Chirurgie Vasculaire Périphérique Pr. TAOUFIQ BENCHEKROUN Soumia Pédiatrie
DECEMBRE 2002
Pr. AL BOUZIDI Abderrahmane* Anatomie Pathologique
Pr. AMEUR Ahmed * Urologie
Pr. AMRI Rachida Cardiologie
Pr. AOURARH Aziz* Gastro-Entérologie
Pr. BAMOU Youssef * Biochimie-Chimie
Pr. BELMEJDOUB Ghizlene* Endocrinologie et Maladies Métaboliques
Pr. BENZEKRI Laila Dermatologie
Pr. BENZZOUBEIR Nadia Gastro-Entérologie
Pr. BERNOUSSI Zakiya Anatomie Pathologique
Pr. BICHRA Mohamed Zakariya* Psychiatrie
Pr. CHOHO Abdelkrim * Chirurgie Générale
Pr. CHKIRATE Bouchra Pédiatrie
Pr. EL ALAMI EL Fellous Sidi Zouhair Chirurgie Pédiatrique
Pr. EL HAOURI Mohamed * Dermatologie
Pr. FILALI ADIB Abdelhai Gynécologie Obstétrique
Pr. HAJJI Zakia Ophtalmologie
Pr. IKEN Ali Urologie
Pr. JAAFAR Abdeloihab* Traumatologie Orthopédie
Pr. KRIOUILE Yamina Pédiatrie
Pr. MABROUK Hfid* Traumatologie Orthopédie
Pr. MOUSSAOUI RAHALI Driss* Gynécologie Obstétrique
Pr. OUJILAL Abdelilah Oto-Rhino-Laryngologie
Pr. RACHID Khalid * Traumatologie Orthopédie
Pr. RAISS Mohamed Chirurgie Générale
Pr. RGUIBI IDRISSI Sidi Mustapha* Pneumo-phtisiologie
Pr. RHOU Hakima Néphrologie
Pr. SIAH Samir * Anesthésie Réanimation
Pr. THIMOU Amal Pédiatrie
JANVIER 2004
Pr. ABDELLAH El Hassan Ophtalmologie
Pr. AMRANI Mariam Anatomie Pathologique
Pr. BENBOUZID Mohammed Anas Oto-Rhino-Laryngologie
Pr. BENKIRANE Ahmed* Gastro-Entérologie
Pr. BOULAADAS Malik Stomatologie et Chirurgie Maxillo-faciale
Pr. BOURAZZA Ahmed* Neurologie
Pr. CHAGAR Belkacem* Traumatologie Orthopédie
Pr. CHERRADI Nadia Anatomie Pathologique
Pr. EL FENNI Jamal* Radiologie
Pr. EL HANCHI ZAKI Gynécologie Obstétrique
Pr. EL KHORASSANI Mohamed Pédiatrie
Pr. EL YOUNASSI Badreddine* Cardiologie
Pr. HACHI Hafid Chirurgie Générale
Pr. JABOUIRIK Fatima Pédiatrie
Pr. KHARMAZ Mohamed Traumatologie Orthopédie
Pr. MOUGHIL Said Chirurgie Cardio-Vasculaire
Pr. OUBAAZ Abdelbarre * Ophtalmologie
Pr. TARIB Abdelilah* Pharmacie Clinique
Pr. TIJAMI Fouad Chirurgie Générale
Pr. ZARZUR Jamila Cardiologie
JANVIER 2005
Pr. ABBASSI Abdellah Chirurgie Réparatrice et Plastique Pr. AL KANDRY Sif Eddine* Chirurgie Générale
Pr. ALLALI Fadoua Rhumatologie
Pr. AMAZOUZI Abdellah Ophtalmologie
Pr. AZIZ Noureddine* Radiologie
Pr. BAHIRI Rachid Rhumatologie Directeur Hôp. Al Ayachi Salé
Pr. BARKAT Amina Pédiatrie
Pr. BENYASS Aatif Cardiologie
Pr. DOUDOUH Abderrahim* Biophysique
Pr. EL HAMZAOUI Sakina * Microbiologie
Pr. HAJJI Leila Cardiologie (mise en disponibilité
Pr. HESSISSEN Leila Pédiatrie
Pr. JIDAL Mohamed* Radiologie
Pr. LAAROUSSI Mohamed Chirurgie Cardio-vasculaire
Pr. LYAGOUBI Mohammed Parasitologie
Pr. RAGALA Abdelhak Gynécologie Obstétrique
Pr. SBIHI Souad Histo-Embryologie Cytogénétique
Pr. ZERAIDI Najia Gynécologie Obstétrique
Pr. ACHEMLAL Lahsen* Rhumatologie
Pr. AKJOUJ Said* Radiologie
Pr. BELMEKKI Abdelkader* Hématologie
Pr. BENCHEIKH Razika O.R.L
Pr. BIYI Abdelhamid* Biophysique
Pr. BOUHAFS Mohamed El Amine Chirurgie - Pédiatrique
Pr. BOULAHYA Abdellatif* Chirurgie Cardio – Vasculaire. Pr. CHENGUETI ANSARI Anas Gynécologie Obstétrique
Pr. DOGHMI Nawal Cardiologie
Pr. FELLAT Ibtissam Cardiologie
Pr. FAROUDY Mamoun Anesthésie Réanimation
Pr. HARMOUCHE Hicham Médecine Interne
Pr. HANAFI Sidi Mohamed* Anesthésie Réanimation
Pr. IDRISS LAHLOU Amine* Microbiologie
Pr. JROUNDI Laila Radiologie
Pr. KARMOUNI Tariq Urologie
Pr. KILI Amina Pédiatrie
Pr. KISRA Hassan Psychiatrie
Pr. KISRA Mounir Chirurgie – Pédiatrique
Pr. LAATIRIS Abdelkader* Pharmacie Galénique Pr. LMIMOUNI Badreddine* Parasitologie
Pr. MANSOURI Hamid* Radiothérapie
Pr. OUANASS Abderrazzak Psychiatrie
Pr. SAFI Soumaya* Endocrinologie
Pr. SEKKAT Fatima Zahra Psychiatrie
Pr. SOUALHI Mouna Pneumo – Phtisiologie
Pr. TELLAL Saida* Biochimie
Pr. ZAHRAOUI Rachida Pneumo – Phtisiologie
DECEMBRE 2006
Pr SAIR Khalid Chirurgie générale Dir. Hôp.Av.Marrakech
OCTOBRE 2007
Pr. ABIDI Khalid Réanimation médicale
Pr. ACHACHI Leila Pneumo phtisiologie
Pr. ACHOUR Abdessamad* Chirurgie générale
Pr. AIT HOUSSA Mahdi * Chirurgie cardio vasculaire
Pr. AMHAJJI Larbi * Traumatologie orthopédie
Pr. AOUFI Sarra Parasitologie
Pr. BAITE Abdelouahed * Anesthésie réanimation Directeur ERSSM
Pr. BALOUCH Lhousaine * Biochimie-chimie
Pr. BENZIANE Hamid * Pharmacie clinique
Pr. BOUTIMZINE Nourdine Ophtalmologie
Pr. EHIRCHIOU Abdelkader * Chirurgie générale
Pr. EL BEKKALI Youssef * Chirurgie cardio-vasculaire
Pr. EL ABSI Mohamed Chirurgie générale
Pr. EL MOUSSAOUI Rachid Anesthésie réanimation
Pr. EL OMARI Fatima Psychiatrie
Pr. GHARIB Noureddine Chirurgie plastique et réparatrice
Pr. HADADI Khalid * Radiothérapie
Pr. ICHOU Mohamed * Oncologie médicale
Pr. ISMAILI Nadia Dermatologie
Pr. KEBDANI Tayeb Radiothérapie
Pr. LALAOUI SALIM Jaafar * Anesthésie réanimation
Pr. LOUZI Lhoussain * Microbiologie
Pr. MADANI Naoufel Réanimation médicale
Pr. MAHI Mohamed * Radiologie
Pr. MARC Karima Pneumo phtisiologie
Pr. MASRAR Azlarab Hématologie biologique
Pr. MRANI Saad * Virologie
Pr. OUZZIF Ez zohra * Biochimie-chimie
Pr. RABHI Monsef * Médecine interne
Pr. RADOUANE Bouchaib* Radiologie
Pr. SEFFAR Myriame Microbiologie
Pr. SEKHSOKH Yessine * Microbiologie
Pr. SIFAT Hassan * Radiothérapie
Pr. TABERKANET Mustafa * Chirurgie vasculaire périphérique
Pr. TACHFOUTI Samira Ophtalmologie
Pr. TAJDINE Mohammed Tariq* Chirurgie générale
Pr. TANANE Mansour * Traumatologie-orthopédie
Pr. TLIGUI Houssain Parasitologie
Pr. TOUATI Zakia Cardiologie
DECEMBRE 2008
Pr TAHIRI My El Hassan* Chirurgie Générale
MARS 2009
Pr. ABOUZAHIR Ali * Médecine interne
Pr. AGADR Aomar * Pédiatrie
Pr. AIT ALI Abdelmounaim * Chirurgie Générale Pr. AIT BENHADDOU El Hachmia Neurologie
Pr. AKHADDAR Ali * Neuro-chirurgie
Pr. ALLALI Nazik Radiologie
Pr. AMINE Bouchra Rhumatologie
Pr. ARKHA Yassir Neuro-chirurgie Directeur Hôp.des Spécialités Pr. BELYAMANI Lahcen* Anesthésie Réanimation
Pr. BJIJOU Younes Anatomie
Pr. BOUI Mohammed * Dermatologie
Pr. BOUNAIM Ahmed * Chirurgie Générale
Pr. BOUSSOUGA Mostapha * Traumatologie-orthopédie
Pr. CHTATA Hassan Toufik * Chirurgie Vasculaire Périphérique
Pr. DOGHMI Kamal * Hématologie clinique
Pr. EL MALKI Hadj Omar Chirurgie Générale
Pr. EL OUENNASS Mostapha* Microbiologie
Pr. ENNIBI Khalid * Médecine interne
Pr. FATHI Khalid Gynécologie obstétrique
Pr. HASSIKOU Hasna * Rhumatologie
Pr. KABBAJ Nawal Gastro-entérologie
Pr. KABIRI Meryem Pédiatrie
Pr. KARBOUBI Lamya Pédiatrie
Pr. LAMSAOURI Jamal * Chimie Thérapeutique
Pr. MARMADE Lahcen Chirurgie Cardio-vasculaire
Pr. MESKINI Toufik Pédiatrie
Pr. MESSAOUDI Nezha * Hématologie biologique
Pr. MSSROURI Rahal Chirurgie Générale
Pr. NASSAR Ittimade Radiologie
Pr. OUKERRAJ Latifa Cardiologie
Pr. RHORFI Ismail Abderrahmani * Pneumo-Phtisiologie
OCTOBRE 2010
Pr. ALILOU Mustapha Anesthésie réanimation
Pr. AMEZIANE Taoufiq* Médecine Interne
Pr. BELAGUID Abdelaziz Physiologie
Pr. CHADLI Mariama* Microbiologie
Pr. CHEMSI Mohamed* Médecine Aéronautique
Pr. DAMI Abdellah* Biochimie- Chimie
Pr. DARBI Abdellatif* Radiologie
Pr. DENDANE Mohammed Anouar Chirurgie Pédiatrique
Pr. EL HAFIDI Naima Pédiatrie
Pr. EL KHARRAS Abdennasser* Radiologie
Pr. EL MAZOUZ Samir Chirurgie Plastique et Réparatrice
Pr. EL SAYEGH Hachem Urologie
Pr. ERRABIH Ikram Gastro-Entérologie
Pr. LAMALMI Najat Anatomie Pathologique
Pr. MOSADIK Ahlam Anesthésie Réanimation
Pr. MOUJAHID Mountassir* Chirurgie Générale
Pr. NAZIH Mouna* Hématologie
Pr. ZOUAIDIA Fouad Anatomie Pathologique
DECEMBRE 2010
Pr.ZNATI Kaoutar Anatomie Pathologique
MAI 2012
Pr. AMRANI Abdelouahed Chirurgie pédiatrique
Pr. BENCHEBBA Driss * Traumatologie-orthopédie
Pr. DRISSI Mohamed * Anesthésie Réanimation
Pr. EL ALAOUI MHAMDI Mouna Chirurgie Générale Pr. EL KHATTABI Abdessadek * Médecine Interne
Pr. EL OUAZZANI Hanane * Pneumophtisiologie
Pr. ER-RAJI Mounir Chirurgie Pédiatrique
Pr. JAHID Ahmed Anatomie Pathologique
Pr. MEHSSANI Jamal * Psychiatrie
Pr. RAISSOUNI Maha * Cardiologie
* Enseignants Militaires FEVRIER 2013
Pr.AHID Samir Pharmacologie
Pr.AIT EL CADI Mina Toxicologie
Pr.AMRANI HANCHI Laila Gastro-Entérologie
Pr.AMOR Mourad Anesthésie Réanimation
Pr.AWAB Almahdi Anesthésie Réanimation
Pr.BELAYACHI Jihane Réanimation Médicale
Pr.BELKHADIR Zakaria Houssain Anesthésie Réanimation
Pr.BENCHEKROUN Laila Biochimie-Chimie
Pr.BENKIRANE Souad Hématologie
Pr.BENNANA Ahmed* Informatique Pharmaceutique
Pr.BENSGHIR Mustapha * Anesthésie Réanimation
Pr.BENYAHIA Mohammed * Néphrologie
Pr.BOUATIA Mustapha Chimie Analytique et Bromatologie Pr.BOUABID Ahmed Salim* Traumatologie orthopédie
Pr BOUTARBOUCH Mahjouba Anatomie
Pr.CHAIB Ali * Cardiologie
Pr.DENDANE Tarek Réanimation Médicale
Pr.DINI Nouzha * Pédiatrie
Pr.ECH-CHERIF EL KETTANI Mohamed Ali Anesthésie Réanimation Pr.ECH-CHERIF EL KETTANI Najwa Radiologie
Pr.EL FATEMI NIZARE Neuro-chirurgie
Pr.EL GUERROUJ Hasnae Médecine Nucléaire
Pr.EL HARTI Jaouad Chimie Thérapeutique
Pr.EL JAOUDI Rachid * Toxicologie
Pr.EL KABABRI Maria Pédiatrie
Pr.EL KHANNOUSSI Basma Anatomie Pathologique
Pr.EL KHLOUFI Samir Anatomie
Pr.EL KORAICHI Alae Anesthésie Réanimation
Pr.EN-NOUALI Hassane * Radiologie
Pr.ERRGUIG Laila Physiologie
Pr.GHFIR Imade Médecine Nucléaire
Pr.IMANE Zineb Pédiatrie
Pr.IRAQI Hind Endocrinologie et maladies métaboliques
Pr.KABBAJ Hakima Microbiologie
Pr.KADIRI Mohamed * Psychiatrie
Pr.MAAMAR Mouna Fatima Zahra Médecine Interne
Pr.MEDDAH Bouchra Pharmacologie
Pr.MELHAOUI Adyl Neuro-chirurgie
Pr.MRABTI Hind Oncologie Médicale
Pr.NEJJARI Rachid Pharmacognosie
Pr.OUBEJJA Houda Chirugie Pédiatrique
Pr.OUKABLI Mohamed * Anatomie Pathologique
Pr.RAHALI Younes Pharmacie Galénique
Pr.RATBI Ilham Génétique
Pr.RAHMANI Mounia Neurologie
Pr.REDA Karim * Ophtalmologie
Pr.REGRAGUI Wafa Neurologie
Pr.RKAIN Hanan Physiologie
Pr.ROSTOM Samira Rhumatologie
Pr.ROUAS Lamiaa Anatomie Pathologique
Pr.ROUIBAA Fedoua * Gastro-Entérologie
Pr SALIHOUN Mouna Gastro-Entérologie
Pr.SAYAH Rochde Chirurgie Cardio-Vasculaire
Pr.SEDDIK Hassan * Gastro-Entérologie
Pr.ZERHOUNI Hicham Chirurgie Pédiatrique
Pr.ZINE Ali* Traumatologie Orthopédie
AVRIL 2013
Pr.EL KHATIB MOHAMED KARIM * Stomatologie et Chirurgie Maxillo-faciale
MAI 2013
Pr.BOUSLIMAN Yassir Toxicologie
MARS 2014
Pr. ACHIR Abdellah Chirurgie Thoracique
Pr.BENCHAKROUN Mohammed * Traumatologie- Orthopédie
Pr.BOUCHIKH Mohammed Chirurgie Thoracique
Pr. EL KABBAJ Driss * Néphrologie
Pr. EL MACHTANI IDRISSI Samira * Biochimie-Chimie
Pr. HARDIZI Houyam Histologie- Embryologie-Cytogénétique
Pr. HASSANI Amale * Pédiatrie
Pr. HERRAK Laila Pneumologie
Pr. JANANE Abdellah * Urologie
PROFESSEURS AGREGES :
DECEMBRE 2014
Pr. ABILKASSEM Rachid* Pédiatrie
Pr. AIT BOUGHIMA Fadila Médecine Légale
Pr. BEKKALI Hicham * Anesthésie-Réanimation
Pr. BENAZZOU Salma Chirurgie Maxillo-Faciale
Pr. BOUABDELLAH Mounya Biochimie-Chimie
Pr. BOUCHRIK Mourad* Parasitologie
Pr. DERRAJI Soufiane* Pharmacie Clinique
Pr. DOBLALI Taoufik* Microbiologie
Pr. EL AYOUBI EL IDRISSI Ali Anatomie
Pr. EL GHADBANE Abdedaim Hatim* Anesthésie-Réanimation
Pr. EL MARJANY Mohammed* Radiothérapie
Pr. FEJJAL Nawfal Chirurgie Réparatrice et Plastique
Pr. JAHIDI Mohamed* O.R.L
Pr. LAKHAL Zouhair* Cardiologie
Pr. OUDGHIRI NEZHA Anesthésie-Réanimation
Pr. RAMI Mohamed Chirurgie Pédiatrique
Pr. SABIR Maria Psychiatrie
Pr. SBAI IDRISSI Karim* Médecine préventive, santé publique et Hyg.
AOUT 2015
Pr. MEZIANE Meryem Dermatologie
Pr. TAHRI Latifa Rhumatologie
JANVIER 2016
Pr. BENKABBOU Amine Chirurgie Générale
Pr. EL ASRI Fouad* Ophtalmologie
Pr. ERRAMI Noureddine* O.R.L
Pr. NITASSI Sophia O.R.L
JUIN 2017
Pr. ABI Rachid* Microbiologie
Pr. ASFALOU Ilyasse* Cardiologie
Pr. KOUACH Jaouad* Gynécologie-Obstétrique
Pr. LEMNOUER Abdelhay* Microbiologie
Pr. MAKRAM Sanaa * Pharmacologie
Pr. OULAHYANE Rachid* Chirurgie Pédiatrique
Pr. RHISSASSI Mohamed Jaafar CCV
Pr. SABRY Mohamed* Cardiologie
Pr. SEKKACH Youssef* Médecine Interne
Pr. TAZI MOUKHA Zakia Gynécologie-Obstétrique
AVRIL 2014
Pr. BOUAYTI El Arbi* Médecine préventive, santé publique et Hyg.
Pr. BOUTAYEB Saber Oncologie Médicale
Pr. EL GHISSASSI Ibrahim Oncologie Médicale
Pr. OURAINI Saloua* O.R.L
Pr. RAZINE Rachid Médecine préventive, santé publique et Hyg.
Pr. ZRARA Abdelhamid* Immunologie
* Enseignants Militaires
2 - ENSEIGNANTS-CHERCHEURS SCIENTIFIQUES
PROFESSEURS/Prs. HABILITES
Pr. ABOUDRAR Saadia Physiologie
Pr. ALAMI OUHABI Naima Biochimie-chimie
Pr. ALAOUI KATIM Pharmacologie
Pr. ALAOUI SLIMANI Lalla Naïma Histologie-Embryologie
Pr. ANSAR M’hammed Chimie Organique et Pharmacie Chimique
Pr .BARKIYOU Malika Histologie-Embryologie
Pr. BOUHOUCHE Ahmed Génétique Humaine
Pr. BOUKLOUZE Abdelaziz Applications Pharmaceutiques
Pr. CHAHED OUAZZANI Lalla Chadia Biochimie-chimie
Pr. DAKKA Taoufiq Physiologie
Pr. FAOUZI Moulay El Abbes Pharmacologie
Pr. IBRAHIMI Azeddine Biologie moléculaire/Biotechnologie
Pr. KHANFRI Jamal Eddine Biologie
Pr. OULAD BOUYAHYA IDRISSI Med Chimie Organique
Pr. REDHA Ahlam Chimie
Pr. TOUATI Driss Pharmacognosie
Pr. ZAHIDI Ahmed Pharmacologie
Mise à jour le 10/10/2018 Khaled Abdellah
Dear God:
A big part of me always revolved around my faith and relationship
with you and so choosing this proficiency I devote my work and
self to your worshipness
and the help of others in the name of your love. Most of my strength and persistence,
I draw from your affection and benediction. I believe in your divine assistance
in everything that i ever did or will do and I am deeply grateful for all
the blessings you’ve granted me with. Today I devote myself to humanity
My Mother Hafida Nassiri:
I don’t think I have ever tried putting into words the way I feel about you.
You ingrained in me the love of knowledge from a very young age and made
sure there were no limits to my dreams, even when that meant me telling everyone in
primary school that all what’s left for me to become a doctor was being inside an
operating room. I grew up admiring the magnificent selfless woman that you are:
managing your passion for teaching and the love and care you have for your family.
You have always supported my decisions and your prayers enlighten my path as my
main aspiration will always be to make you proud.
I love you more than words can say.
My Father Larbi Essangri:
Being your daughter connotes growing in the shadow of a man who worked
hard, regardless of all to give the best possible life for his children and so it’s only
natural to strive for success. You raised us in an affluence of love and affection,
and made sure we were reminded of how strong and beautiful we are.
You oversaw that we knew our worth and grew up to be independent and
your faith in each one of my steps will always incite me to be better.
I love you.
My Brother Yassine:
Apart from being my bigger brother, you were always a good confident
and supported me through everything (apart from when we had occasional war times).
Your are the most kind hearted and affectionate man and i can never properly
express how glad i am to be your sister. I can make your life hard sometimes
but that’s what siblings are for. I will always have your back. I love you.
My Sister Hiba:
I cannot write about you without mentioning first that no matter
how grown up you are you will always be my baby sister and that no matter
how close or far we are, the love and care I have for you is bigger.
You’ve allowed me to grow a lot in the past few years and for that I thank you.
I admire the fighter and ambitious “young” woman that you are and believe
My Grandmothers Yema and Jedda:
I would like to dedicate this work to the hard work and not so easy
lives you have led. My respect and admiration for you in endless.
To the Memory of my Grandfathers:
To Bassidi: I can still recall the writing lecons and struggle you had
to get me to hold my pencil properly, as well as your speeches about
the importance of doing Good to others. You were an amazing role model
and part of me will always be the values you taught me. May your soul rest in peace.
To my grandfather Ahmed Essangri: This work is the representation of my love and
recognition. May your soul rest in peace.
To the Nassiri and Essangri families:
To my uncles and aunts, the dear ones who were able to make it and the ones
who wished to be here, I dedicate this work to each one of you. Accept this work
My best friend: soukaina al hadrati
It’s been 10 years and we made it without killing each other! Our friendship
had its ups and downs but we always managed to find our way back and
I know that following our dreams is scary and may mean not having the
life we imagined (us growing old somewhere and never having a THIRD)
but I am SURE we will manage… and you know how sure I can be about things.
I love you. You will always be my person
.
Nouha Labassi:
To the dear friend, the sister, the smart and the strong person
that you are and that I deeply admire. Your friendship means a lot to me.
I will always be grateful for the guidance, affection and support I received from
you and walid. I love you dearly.
Youssef Aadi:
Do not get overly excited because i wrote your name. I didn’t. This is an illusion…
To the memory of the best night shifts that put you in my way
(and me in yours of course).I applaud your goodness as a person and as a doctor.
I love you buddy.
Nada El kadiri:
No matter how far apart we are, you always hold a special place in my heart.
Your friendship is something I hold on to profoundly. I love you
.
Ollie Mae Nicoll:
To the Slilou of my cafe creme … although I drink my coffee black and sugarless
like my soul now. With 6142km apart we still manage to be part of almost
everything in each others lives (and you manage to encourage all my crazy ideas).
This is a reminder of how much your friendship means to me. I love you.
PS: yes i researched the distance to look extra smart; this is a thesis after all
-
Kholoud Salahuddin Afifi:
There is some telepathic soul connection going on here, which we’re sure
of just as much as I am sure that in some other life you were my twin. I admire the
strong person that you are and can’t wait to see you.
Thank you for being my dear friend.
Ilias belkhairi:
Who would have thought that sitting next to you as a punishment would
lead to such long and great friendship and that I can brag about having a childhood
friend now? You mean a lot to me. Thank you for always being there
and to our bright futures.
Kholoud Houssaini:
To the newest bird and most natural connection: I look forward to the future of our
friendship… To growth, soul searching and bright futures.
Sara Bortolani :
La circostanze hanno voluto che io non potessi vederti proclamata neurologa e che tu
non possa vedere me nel giorno della mia laurea. Ma guardaci. Siamo diventate
To Chaymae Al hadrati & Imad eddine chahboun:
For being the good friends and almost family
To Lyn abu sidu
To my friends and collegues:
Youssef Garda, Hamza Labiad, Basma Lahmer, Maha El Ouadi,
Amine Chibani, Nassima Belhaj …
To general surgery professor Amine souadka:
Director of thesis
In this past year, having been able to learn from you gave me the opportunity
to absorb the energy, passion and encouragement you spread around as a professor,
researcher and mostly role model; and for that i am deeply honored. I could never
thank you enough for taking me under your wing, giving me the amazing
opportunities you did and somehow unconditionally believing in me. The knowledge
you passed on to me allowed me to grow so much and become a better version of myself
as a person and researcher and I can only wish to be able to follow your example.
I profoundly thank you for having my best interest and success in mind and could
never fairly phrase how much your support means to me. My respect and admiration
To general surgery professor and head
of digestive oncological surgery Mohcine Raouf:
President
of thesis
I would like to express my admiration to the amazing research project
and great learning opportunities as well the great work environment in your
department. I am very honored by your presence as president of my thesis jury.
To general surgery professor Mohammed
Anass Majbar: Jury of thesis
Foremost, I would like to express how honored I am for being able to carry
on with the research project you started; I also would like to express my respect
and admiration for your amazing work and expertise. I thank you for doing me the
honor of being part of my thesis jury and judging my merit to carry the title
of Medical Doctor.
To gastroenterology professor Leila amrani:
Jury of thesis
I thank you for doing me the honor of being part of my thesis jury
and judging my merit to carry the title of Medical Doctor.
To general surgery professor El malki Hadj Omar:
Jury of thesis
I thank you for doing me the honor of being part of my thesis jury
to evaluate my work and judge my merit to carry the title of Medical Doctor.
LIST OF FIGURES
Figure 1: Number of new cases and deaths in 2018 linked to cancers ...3 Figure 2 : Age standardized incidence rates of colorectal cancer in the male population worldwide ...3 Figure 3 : Age standardized incidence rates of colorectal cancer in the male population worldwide ...4 Figure 4: Sagittal view of the sigmoid colon, the rectum and anal canal showing the sacral and
anorectal flexures ...6
Figure 5: Sagittal view of the rectum and anal canal showing the angle variation of the anorectal
flexure when the EAS and puborectalis are contracted or relaxed ...7
Figure 6: Coronal view showing the upper, middle and lower portions of the rectum and the anal
canal ...8
Figure 7 : Sagittal view showing the anatomic and surgical anal canal ...9 Figure 8: Coronal view showing the anal sphincter complex and levator ani complex ... 12 Figure 9: Pelvic view of the levator muscles demonstrating its four main components: puborectalis,
pubococcygeus, iliococcygeus, and coccygeus (From Gordon PH, Nivatvongs S [eds]: Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 18.) ... 13
Figure 10: Sagittal view showing the rectum’s peritoneal covering and nearby organs in male and
female... 14
Figure 11: transversal view showing the pelvic fascia in their relationship with the mesorectum [41]
... 17
Figure 12: Sagittal view showing the pelvic fascia (From Gordon PH, Nivatvongs S [eds]: Principles
and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 10.) ... 18
Figure 14 : sagittal view showing the lines of mesorectal excision ... 20 Figure 15: Coronal view of the low rectum showing the nearby structures at the limits of mesorectal
Figure 16: Anorectal arterial blood supply. (From Gordon PH, Nivatvongs S [eds]: Principles and
practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 24.) ... 21
Figure 17: Anorectal venous drainage. (From Gordon PH, Nivatvongs S [eds]: Principles and
practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 30.) ... 22
Figure 18: Lymphatic drainage of rectum and anal canal from Gordon PH, Nivatvongs S [eds]:
Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 32. ... 23
Figure 19: Nerve supply of the rectum and anal canal. ... 24 Figure 20: the limits of excision for a rectal tumor ... 26
Figure 21 : The Wexner score ... 34
Figure22: The VAIZEY score ... 35 Figure 23: The LARS score ... 36 Figure 23: The American Association of Orthopaedic Surgeons (AAOS) Cross-cultural adaptation
protocol ... 40
Figure 24: Patient selection flowchart ... 45 Figure 25: Bland–Altman plot with 95% limits of agreement illustrating the difference between
LARS scores at the first and second test. ... 54
Figure 26 : Bland–Altman plot with 95% limits of agreement illustrating the difference between
WEXNER scores at the first and second test. ... 55
Figure 27 : Boxplot showing the LARS total score median values according to rectal
tumor location... 60
Figure 28 : Boxplot showing the LARS total score median values according to anastomosis type .... 60 Figure 29 : Boxplot showing the LARS total score median values according to radiochemotherapy . 61 Figure 30 : Boxplot showing the LARS total score median values according to the type of mesorectal
excision ... 61
Figure 31 : Boxplot showing the WEXNER total score median values according to rectal tumor
location ... 62
Figure 32 : Boxplot showing the WEXNER total score median values according to anastomosis
type ... 63
Figure 33 : Boxplot showing the WEXNER total score median values according to
Figure 34: Boxplot showing the WEXNER total score median values according to type of
mesorectal excision ... 64
Figure 35 : Scatter plot showing the correlation between the WEXNER and LARS scores ... 65
LISTE OF TABLES
Table I : Clinical and demographic characteristics of patients. ... 52 Table II : Agreement levels of the LARS categories and score items between the test and retest ... 54 Table III : Agreement levels of the WEXNER score items between the test and retest ... 56 Table IV: Convergent validity of the LARS score ... 57 Table V : Convergent validity of the WEXNER score ... 58 Table V : Literature review results of the available international validations of the LARS and
SUMMARY
INTRODUCTION ...1 I. SURGICAL ANATOMY : ...5 ❖ Rectum: ...5 ❖ Anal canal : ...8 ❖ Anal sphincter : ... 10 -Internal anal sphincter :... 10 - External anal sphincter :... 10 - The conjoined longitudinal muscle : ... 11 ❖The pelvic floor : ... 12 ❖Rectum and peritoneum : ... 13 ❖The Pelvic fascia: ... 15 ❖The Rectal spaces : ... 16 ❖Rectum and mesorectum : ... 19 ❖Rectum vasculature : ... 21 - Arterial Supply: ... 21 - Venous Drainage: ... 22 -Lymphatic Drainage: ... 23 - Nerve supply: ... 24 II.-SURGICAL MANAGEMENT OF RECTAL CANCER : ... 25 ❖Low anterior resection (LAR) : ... 25 ❖Principles of the resection : ... 26 ❖Surgical steps : ... 27 ❖Types of anastomoses: ... 28 III.-PATHOPHYSIOLOGY OF THE LAR: ... 29 ❖Normal continence :... 29 ❖Incontinence : ... 30 IV.-THE LOW ANTERIOR RESECTION SYNDROME : ... 32V.-INCONTINENCE ASSESSMENT TOOLS : ... 32 ❖The Jorge- wexner score : ... 33 ❖The vaizey score : ... 34 ❖The LARS score : ... 35 METHODOLOGY: ... 38 I.-QUESTIONNAIRE ELABORATION : ... 41 ❖Translation: ... 41 ❖Back-translation: ... 41 ❖Pre-test: ... 41 II.-PATIENT REPORTED OUTCOME MEASURES : ... 42 ❖LARS score: ... 42 ❖Wexner score : ... 42 ❖EORTC QLQ-C30: ... 43 III.-PARTICIPANTS SAMPLING AND DATA COLLECTION: ... 44 IV.-PSYCHOMETRIC PROPERTIES: ... 46 ❖Reliability : ... 46 -Internal consistency: ... 46 - Test - retest : ... 46 ❖Validity : ... 47 - Convergent validity: ... 47 - Discriminant validity : ... 48 V.-STATISTICAL ANALYSIS: ... 48 VI.-INTERNATIONAL DATABASE AND ETHICS CONSIDERATIONS: ... 49
RESULTS ... 50
I.-TRANSLATION : ... 51 II.-PATIENTS CLINICAL AND DEMOGRAPHIC CHARACTERISTICS : ... 51 III.-RELIABILITY : ... 53 ❖Internal consistency : ... 53
❖Test-retest: ... 53 -LARS reliability : ... 53 -WEXNER reliability:... 55 IV.-VALIDITY:... 57 ❖Convergent validity : ... 57 -LARS score : ... 57 -WEXNER score: ... 58 ❖Discriminant validity : ... 59 -LARS discriminant validity: ... 59 -WEXNER discriminant validity:... 62 V.-CORRELATION BETWEEN THE LARS AND WEXNER: ... 65
DISCUSSION ... 66
I.-PRIOR VALIDATIONS OF THE LARS AND WEXNER SCORE : ... 67 II.-MEAN FOLLOW UP TIME : ... 69 III.-RELIABILITY : ... 69 ❖Internal consistency: ... 69 ❖Test-retest reliability: ... 70 IV. VALIDITY : ... 70 ❖Convergent validity : ... 70 ❖Divergent validity : ... 71 ❖Correlation between low anterior resection syndrome questionnaires: ... 73
CONCLUSION ... 74 ABSTRACT ... 76 APPENDIX ... 80 REFERENCES ... 91
1
2
Colorectal cancer is a critical global health issue with 1 849 518 (10.2%) new cases and 880 792 (9.2%) deaths in 2018. It’s the third most commonly diagnosed malignancy and the second leading cause of cancer-related deaths in the world. [1] Its burden is expected to increase by 60% to more than 2.2 million new cases and 1.1 million cancer deaths by 2030 [2,3] ) Similarly, the number of deaths in subjects with rectal cancer has been projected to rise by 71.5% until 2035.
These numbers are the result of population growth and aging, [2,3] alongside being the reflection of already established risk factors of CRC such as high BMI, physical inactivity, smoking, alcohol consumption, diets rich in red and processed meat, artificially sweetened foods, and salt, with minimal intake of fruits and vegetables [4]. In fact, colorectal cancer is being increasingly considered one of the clearest markers of epidemiological and nutritional transition, with increasing incidence rates of this cancer among others, offsetting infection-related cancers in countries undergoing societal and economic changes. Moreover, the incidence of CRC in younger individuals aged under 50 is progressively rising, accounting for up to 11% of all male CRCs, 10% of all female CRCs, and 7% of all CRCs occurring before 40 years of age. [5];[6].
Opposingly to the aforementioned facts, CRC linked death rate showed declining trends in the past years [7] mirroring the effects of preventive strategies such as early detection [8] , colonoscopy [9] , polypectomy [10] as well as the improvements in perioperative care,chemotherapy and radiotherapy throughout the adoption of multidisciplinary management [11]
3
In Morocco, colorectal cancer is the second most frequent digestif cancer after stomach cancer, the tenth most frequent cancer for male patients and the sixth most frequent for female patients in Casablanca. [12]
Figure 1: Number of new cases and deaths in 2018 linked to cancers
Figure 2 : Age standardized incidence rates of colorectal
4
Figure 3 : Age standardized incidence rates of colorectal
cancer in the male population worldwide
Survival rates for colorectal cancer have been improving, with 5-year survival rate for patients at the early stage of CRC (stages I and II) above 60% and up to 10% for patients beyond stage III when distant metastases have already occurred. [13] This has been attributed to the multimodal management of rectal cancer which involves a multidisciplinary team of cancer specialists with expertise in gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology. [14] Notwithstanding the enhanced oncological outcome and long term survival rate, this lengthened survivorship is also correlated to deteriorating anorectal function, impaired physical functioning and everyday life multiple disease- and treatment-related symptoms such as pain, bowel dysfunction, and fatigue which negatively affect psychological, emotional, social, and role functioning through fear, anxiety, sleep disruption, and depression making it therefore pivotal to assess and attempt to improve the quality of life of CRC patients. [15]
5
Almost 80% of patients having undergone sphincter preserving surgery report a set of symptoms including difficulty emptying the bowel, faecal urgency and faecal incontinence, all encompassed by the term : low anterior resection syndrome (LARS). Bryant and al suggested a definition that is “disordered bowel function after rectal resection, leading to a detriment in quality of life” [16]
This syndrome previously thought to be transient, is shown to persist for years after resection, hence the crucial need to include the LARS among the adverse effects and as a part of the surgical outcome assessment. Accordingly, many tools have been developed to measure the degree of LARS and make this complex syndrome amenable to discussion, namely the LARS and WEXNER scores. These questionnaires, as with more traditional health-care assessment tools need to be tested for reliability and validity.
I. SURGICAL ANATOMY :
❖ Rectum:
The rectum is the most distal portion of the large intestine, bound superiorly by the transition from the sigmoid colon and converging at the level of the dentate line into the anal canal distally. This transition is marked by the cessation of the mesocolon, coalescence of taenia coli, loss of appendices epiploicae and the fusion of the surgical mesocolon. The rectum has a length varying from 12 to 15 cm and is devided into two segments, the first being the rectal ampulla, which is known for it’s expansion from 8 to 16cm according to varying filling states, and the second being the anal canal.
6
The rectum can also be divided into an upper, middle, and lower portion located at a distance of 15-12cm, 11-7 cm and 6-0 cm respectfully.
Its course is marked by two anterior-posterior flexures, the first following the concavity of the sacrum as the sacral flexure and the second coursing anteriorly as the anorectal flexure. This latter presents at an angle of 90° at rest, whereas with voluntary squeeze of the EAS and puborectalis muscle, the angle becomes more acute (70° ) in order to close off the anal canal and maintain continence. It’s during defecation that it widens to 110-130° as the puborectalis and EAS relax in order to straighten out the anorectal junction, allowing stool to pass through. [20]
Figure 4: Sagittal view of the sigmoid colon, the rectum and anal canal showing
7
Figure 5: Sagittal view of the rectum and anal canal showing the angle variation of the
anorectal flexure when the EAS and puborectalis are contracted or relaxed
Additionally the rectum presents three lateral curvatures - superior inferior and middle oriented respectfully to the right and left. Each of these curves presents on the inside a transverse sickle-shaped luminal fold: the valves of Houston, the rectal folds or the semi-lunar transverse folds; the middle fold being the most prominent one. This latter also called the kohlrasch’s valve, marks the anterior peritoneal reflection which is about 7-9 cm above the anal verge in men and 5-7.5 cm in women. These folds contribute significantly to the support of the weight of the fecal matter and therefore the prevention of fecal incontinence. [21]
8
Figure 6: Coronal view showing the upper, middle and lower portions
of the rectum and the anal canal
❖ Anal canal :
The anatomical anal canal measures approximately 2 cm and extends from the dentate line to the anal verge with two thirds above the pectinate line and one third below it. It is surrounded by the IAS, EAS, and the puborectalis muscle.
Another definition of the anal canal was suggested by Milligan and Morgan, measuring the “surgical” anal canal from the anal verge to the anorectal ring (levator ani) with a length of 4.4 cm and 4.5 cm in men and women respectively.[22] This definition is useful in a physiologic and surgical manner
9
as this longer anal canal begins at a region with higher intraluminal pressure (end of the ampulla), thereby correlating better to digital, sonographic and manometric examination. [23–25]
Transitionning to the anal canal, the epithelium from the rectum (columnar epithelium) becomes a squamous epithelium (also called anal mucosa) with the transition line marked by the dentate line. This squamous epithelium is none keratinizing above the anal verge and pigmented and keratinized with skin appendages below it (eg, hair, sweat glands, and sebaceous glands). It’s located in the midportion of the anal canal and contains anal crypts or colomns at the base of which are anal glands and anal papillae. More inferiorly are the anal valves which are transverse folds of the mucosa containing vascular cushions (expansions of vascular tissue within the mucosa) which can expand to form a seal that aids in maintaining resting anal tone and promoting continence.
10
❖ Anal sphincter :
The anal sphincter complex consists of the internal anal sphincter (IAS), external anal sphincter (EAS), puborectalis sling, and longitudinal rectal muscle which layer up from inside to outside as the anal mucosa, smooth muscle IAS layer, fat-containing intersphincteric space with conjoined longitudinal muscle layer, and outer striated EAS muscle layer. [27,28]
Internal anal sphincter :
As the rectum inserts into the pelvic diaphragm, the inner circular muscle of the rectum becomes the IAS being 2-3 cm long and 5-8mm thick with an increasing thickness near the anal verge. The IAS terminates at 1 cm proximal to the distal edge of the EAS. The innervation is due to both intrinsic myogenic [29] and extrinsic autonomic neurogenic properties [30,31] insured by the inferior pelvic plexus and splanchnic nerves (S2–4). This provides a natural barrier to the involuntary loss of stool through its ability to maintain a continuous state of partial contraction and only relax in response to rectal distension.
The IAS is palpable through digital examination as a rigid cylinder, particularly when the striated EAS is completely relaxed.[28,32]
External anal sphincter :
The EAS is the expansion of the levator ani muscles and surrounds the anal canal, IAS, and conjoined longitudinal muscle in a cylindrical conformation. It is approximately 2.7 cm high, but is anteriorly shorter in women being approximately 1.5 cm, and extends approximately 1 cm beyond the internal sphincter.
11
The nerve supply is bilaterally insured by the inferior rectal branch of the pudendal nerve (S2, S3) and the perineal branch of the fourth sacral nerve (S4). Unlike other skeletal muscles that are inactive at rest, the EAS along with the pelvic floor muscles maintains continuous unconscious resting electrical tone [33]. This special activity is due to a reflex arc made up of stretch receptors in both levator ani muscles and the anal sphincters, through an afferent neurone to the cauda equina and an efferent motor neurone to the muscles[34]. This resting tone varies to the intra-abdominal pressure and the Valsalva maneuver as well as through voluntary contraction for a short period.[35] In fact it can contract to more than double the resting tone of the anus when stimulated and is responsible for the anal canal’s squeeze pressure[36]
The conjoined longitudinal muscle :
The CLM, also called the longitudinal anal muscle, has been described as a vertical layer of muscular tissue within the intersphincteric space between the IAS and the EAS. It begins at the anorectal ring as an extension of the longitudinal rectal muscle fibers and descends caudally where it’s joined by striated muscle fibres from the puborectalis, hence the term “conjoined” longitudinal muscle. The fibro-elastic tissue of the longitudinal layer is continuous with the fibro-elastic network outside the sphincter to the perianal skin forming the corrugator cutis ani, which constitutes an intra-sphincteric fibro-elastic network passing through the external sphincter. [28,32]
12
Figure 8: Coronal view showing the anal sphincter complex
and levator ani complex [37]
❖ The pelvic floor :
The pelvic floor is an intricate composite of muscles, fascia, and ligaments that functions to provide support to the pelvic organs. It consists of the levator ani muscles that lie within the endopelvic fascia superiorly, the perineal membrane inferiorly, and the perineal body beneath it providing additional support to the anal sphincter.
The levator ani consists of four major muscles namely pubococcygeus, ileococcygeus, ischiococcygeus and puborectalis with distinct muscle fascicle orientation for the three which contribute to the maintain of a constant resting and closing off the anal sphincter [38]. The urogenital hiatus is an opening in this muscular complex through which passes the rectum [39].
13
On the other hand, the perineal body is made out of the intersection of the striated external anal sphincter (EAS), superficial transverse perinei, deep transverse perinei, and bulbospongiosus muscles all functionning in purse string morphology. [32]
Figure 9: Pelvic view of the levator muscles demonstrating its four main components:
puborectalis, pubococcygeus, iliococcygeus, and coccygeus (From Gordon PH, Nivatvongs S [eds]: Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis,
1999, Quality Medical Publishing, p 18.)
❖ Rectum and peritoneum :
The rectum is the continuation of the sigmoid colon as it loses its mesentery, becoming entirely free on its posterior aspect.The peritoneum covers the upper two-thirds of the rectum anteriorly and only the upper third laterally. The lower third of the rectum is entirely devoid of peritoneal covering. The peritoneum covering the upper third of the rectum is reflected onto the pelvic sidewalls to form the pararectal fossa and onto the seminal vesicles in the male and vagina in the female to form the rectovesical and rectovaginal pouch respectively.
14
Figure 10: Sagittal view showing the rectum’s peritoneal covering
15
❖ The Pelvic fascia:
- Fascia propria of the rectum (FPR): As the lower third of rectum is not covered by peritoneum, it is enveloped, along with the mesorectum, by a “sock” shape fascial layer which is removed as an entire package during mesorectal excision. It fuses with the endopelvic fascia and the presacral fascia respectively.
- Endopelvic fascia : covers the floor and sidewalls of the pelvis as well as the origin of the levator ani muscles.
- Presacral fascia: covers the posterior aspect of the mesorectum anteriorly to the sacrum as well as the promontory In the posterior midline descending along into the pelvis and spreading anteriorly and laterally.
- Denonvilliers’ Fascia : separates the mesorectum anteriorly from the rest of the pelvic organs, namely the bladder, seminal vesicles, vasa deferentia, ureters and prostate and both neurovascular (genitourinary) bundles in men and the vagina as well as the genitourinary neurovascular bundles in women.
- Waldeyer’s fascia or retro-sacral fascia: this fascia is a subject of controversy in anatomical texts between considering it a fascia or a ligament. It is described as the thickening of the presacral fascia that descends to meet the mesorectal fascia about 3-5 cm from the anorectal junction and which dissection is important to the full mobilization of the rectum.
- Parietal fascia : is the lateral extension of the Denonvilliers’ fascia and it separates the mesorectal compartment from the lateral pelvic wall. It also adheres to the presacral fascia and encases the hypogastric nerves and the pelvic splanchnic nerves, which run through the lateral pelvic walls.
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- lateral rectal ligaments: these fibrous formations are subject of controversy as many anatomists disagree about not only their position but also their existence while others think of them as lateral condensations of the endopelvic fascia.
Surgical implications of rectal fascia:
Separation of the mesorectum and parietal fascia must be done with caution as any violation of the mesorectal fascia predisposes to tumor local recurrence while the violation of parietal pelvic fascia may result in injury of the presacral venous plexus. Accordingly, the dissection should be done on the avascular “yellow side of the white”.
Moreover, the recognition and dissection of the rectosacral fascia close to its anchoring on the rectal wall increases the mobility of the distal rectum and ensures dissection along the correct plane.
Dissecting close to the denonviller’s fascia or the rectogenital septum is linked with great risk of neurovascular involvement as it contains small nerve fibers and vessels which could result in some degree of urogenital dysfunction.[40]
❖ The Rectal spaces :
- Retrosacral space: separates the rectal and pelvic fascia and extends down to the pelvic floor.
- Presacral space: separates the parietal pelvic fascia and the sacrum and contains the origin of parasympathetic pelvic splanchnic nerves as well as the medial and lateral sacral arteries.
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- Retro-rectal space: an avascular nerve free space separating the waldeyer’s fascia and rectal fascia along the surface of the sacrum, which plays a pivotal role in the dorsal mobilisation of the rectum during the TME.
Figure 11: transversal view showing the pelvic fascia in their relationship
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Figure 12: Sagittal view showing the pelvic fascia (From Gordon PH, Nivatvongs S [eds]:
Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 10.)
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Figure 14: transversal view at the level of the midrectum showing the lateral ligaments
❖ Rectum and mesorectum :
The mesorectum is the remnant of the embryological hindgut mesentery, and consists of a cut of connective tissue and fat that surround the rectum enveloped within the mesorectal fascia and in some areas by the peritoneum. It is bulkier posteriorly with variable thickness. The mesorectum logges the epirectal and pararectal lymph nodes as long as the superior rectal vessels being thereby the earliest and most frequent ones that might be involved when tumor spread occurs.[42,43] This structure represents an important principle in rectal cancer surgery as successful outcome depends on the removal of the rectum with an intact mesorectum.[44] Between the mesorectal fascia and parietal pelvic fascia is an avascular areolar tissue plane, demonstrated surgically as the ‘Holy Plane of Heald’ and allows a histopathological landmark for comparison of quality of surgical resection. [45,46]
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Figure 13 : sagittal view showing the lines of mesorectal excision [47]
Figure 14: Coronal view of the low rectum showing the nearby structures
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❖ Rectum vasculature :
Arterial Supply:
The superior rectal artery, emerging from the inferior mesenteric artery.
The middle rectal arteries, originating from the internal iliac arteries, supply to distal rectum and proximal anal canal. The presence of these arteries is variable.
The inferior rectal arteries arise from the internal pudendal artery, which is a branch of the internal iliac artery.
These arteries traverse the ischioanal fossa on both sides of the anal canal feeding the sphincter muscles. Intramural collaterals exist between the superior and inferior rectal arteries at the level of the dentate line in the submucosa. [49]
Figure 15: Anorectal arterial blood supply. (From Gordon PH, Nivatvongs S [eds]:
Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 24.)
22 Venous Drainage:
Blood returns from the rectum and anal canal into either the portal or systemic systems. Most of the blood from the rectum drains into the superior hemorrhoidal vein that ultimately drains into the portal system via the inferior mesenteric vein. The lowermost portion of the rectum and the anal canal drain into the internal iliac veins directly through the middle rectal veins and the inferior rectal veins.
Figure 16: Anorectal venous drainage. (From Gordon PH, Nivatvongs S [eds]:
Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 30.)
23 Lymphatic Drainage:
Mainly following the arterial supply, the rectum drains via the superior rectal lymphatics to the inferior mesenteric lymph nodes in the retroperitoneum and laterally to the internal iliac nodes along the middle and inferior rectal vessels through the ischioanal fossa. Lymph drainage from below the dentate line drains to the inguinal nodes.
Figure 17: Lymphatic drainage of rectum and anal canal from Gordon PH,
Nivatvongs S [eds]: Principles and practice of surgery for the colon, rectum and anus, ed 2, St Louis, 1999, Quality Medical Publishing, p 32.
24 Nerve supply:
Rectum and anal canal are supplied by superior, middle and inferior rectal plexuses. The parasympathetic fibers of this synapse have their postganglionic neurons in the myenteric plexus of the rectum wall. Also fibers ascend from inferior hypogastric plexus to superior hypogastric and aortic plexus to reach inferior mesenteric plexus which innervates descending and sigmoid colon by traveling up along left colonic wall.
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II. SURGICAL MANAGEMENT OF RECTAL CANCER :
Successful resection of rectal cancer is technically challenging due to the complex anatomy within the pelvis and risk of urinary and sexual dysfunction. Patient characteristics, such as a narrow android pelvis or increased visceral fat, represent further difficulties as well.
Prior to surgery, determination of patient’s fitness and general status is primordial. In addition to that, it is important to assess for metastatic disease through imaging of the chest, abdomen, and pelvis and measure the carcino-embryonic antigen (CEA). This will also allow staging of the tumor and determining the CRM in addition to planning neoadjuvant treatment and resection. Use of infection-prevention measures and deep venous prophylaxis is standard for these major procedures.
❖ Low anterior resection (LAR) :
LAR is defined as resection of the rectum with total or partial mesorectal excision and colo-rectal or -anal anastomosis which will be sometimes protected by a temporary stoma. Total mesorectal excision exploits an embryologic avascular perimesorectal plane to extract a cylindrical specimen of rectum and mesorectum. Preservation of nerves critical to normal sexual and bladder function is a hallmark of the technique.
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Figure 19: the limits of excision for a rectal tumor
❖ Principles of the resection :
- Tumor in the rectosigmoid flexure or upper rectum (above 12 cm): The rectum and mesorectum are divided 5 cm below the tumor. Avoid coning from the mesorectal fascia to the bowel (the total mesorectum must be resected in all 5 cm). A small remnant of the mesorectum is spared.
- Tumor at level 8-12 cm: Bowel and mesorectum is resected 5 cm below the tumor which means TME for all practical purposes.
- Tumor at 5 to 9 cm: total mesorectal excision all the way to the pelvic floor. Adequate distance on the bowel wall < 1 cm.
![Figure 7 : Sagittal view showing the anatomic and surgical anal canal [26]](https://thumb-eu.123doks.com/thumbv2/123doknet/15037145.690545/46.892.137.756.596.978/figure-sagittal-view-showing-anatomic-surgical-anal-canal.webp)
![Figure 8: Coronal view showing the anal sphincter complex and levator ani complex [37]](https://thumb-eu.123doks.com/thumbv2/123doknet/15037145.690545/49.892.137.776.99.482/figure-coronal-view-showing-sphincter-complex-levator-complex.webp)
![Figure 11: transversal view showing the pelvic fascia in their relationship with the mesorectum [41]](https://thumb-eu.123doks.com/thumbv2/123doknet/15037145.690545/54.892.158.781.332.809/figure-transversal-view-showing-pelvic-fascia-relationship-mesorectum.webp)
