ΚΑΡΚΙΝΟΣ ΟΡΘΟΥ

ΧΕΙΡΟΥΡΓΙΚΗ ΕΠΕΜΒΑΣΗ

ΔΥΝΑΤΟΤΗΤΕΣ ΚΑΙ ΠΕΡΙΟΡΙΣΜΟΙ

ΔΗΜΗΤΡΗΣ Π. ΚΟΡΚΟΛΗΣ

ΧΕΙΡΟΥΡΓΟΣ

ΔΙΔΑΚΤΩΡ ΠΑΝΕΠΙΣΤΗΜΙΟΥ ΑΘΗΝΩΝ

Α.Ο.Ν.Α. «Ο ΑΓΙΟΣ ΣΑΒΒΑΣ»

EPIDEMIOLOGY

2015 Estimates

• New cases: 96,830 (colon); 40,000 (rectal)• Deaths: 50,310 (colon and rectal combined)

• Death rate over last 20 years declining• Screening and improvements in treatment

Anatomic Location of CRC

Cecum 14 %

Ascending colon 10 %

Transverse colon 12 %

Descending colon 7 %

Sigmoid colon 25 %

Rectosigmoid junct.9 %

Rectum 23

%

30%

Rectal Cancer

Surgery is the mainstay of treatment of RC After surgical resection, local failure is

common Local recurrence after conventional surgery:

15%-45% (average of 28%)

Radiotherapy significantly reduces the number of local recurrences

Predicting risk of recurrence in RC

Surgery-related

-Low anterior resection

-APR

-Excision of the

mesorectum

-Extend of

lymphadenectomy

-Postoperative anastomoticleakage

-Tumor perforation

Tumor-related-Anatomic location

-Histologic type

-Tumor grade

-Pathologic stage

-radial resection margin

-neural, venous, lymphatic invasion

Incidence of local failure in RC

T1-2,No,Mo <10% T3,No,Mo 15-35% T1,N1,Mo 15-35% T3-4,N1-2,Mo 45-65%

The

Radical excisionTotal Mesorectal Excision(TME)

Introduced by RJ Heald in 1979 Use of sharp dissection under vision to mobilize the rectum rather than the

conventional blunt finger dissection First series of 112 pts: 5yr LR 2.9% and survival 87.5%

Local recurrence: Conventional surgery: 11.7 - 37.4% TME surgery: 1.6 - 17.8%

Higher leak rates reported possibly due to: Devascularization of distal rectal stump Lower anastomosis Other factors: stomas, drains

TME - Trials

Multi-institutional r/w of conventional to TME surgery found large difference in LR (4-9 vs 32-35%) and 5yr survival (62-75 vs 42-44%)

Eur J Surg Oncol 25, 1999

Norwegian Rectal Cancer Grp: Experiencing LR 25+% 1794 pts enrolled (1395 TME vs 229 conventional) LR of 6 vs 12% (30m) and 4yr survival of 73 vs 60% No difference in anastomotic leak rate (10%) & mortality (3%)

Dutch trial the largest prospective trial of 1861 pts demonstrated 2yr LR of 5.3% (TME 8.2% vs TME+XRT 2.4%) Operative mortality (3.5 vs 2.6%) and anastomotic leak (11 vs 12%)

Circumferential resection margin

TME - CRM

TME Specimen

5–10%5–10%

Blunt dissection Blunt dissection TME TME

LR 20–40%LR 20–40%

ADEQUACY OF CIRCUMFERENTIAL RESECTION MARGINS

Fascial plane In mesorectum In/on muscularis

Dataset for colorectal cancer (2° edition), RCOP, 2007

SURGERY QUALITY:EFFECT OF THE PLANE OF SURGERY ON LOCAL

RECURRENCE

Copyright © American Society of Clinical Oncology

Nagtegaal, I. D. et al. J Clin Oncol; 26:303-312 2008

LOCAL RECURRENCE AND CRM

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• Cure

• Local control

• Sphincter preservation

• Preservation of sexual

and urinary function

• Cure

• Local control

• Sphincter preservation

• Preservation of sexual

and urinary function

GoalsGoals

TME - Distal resection margin

Not clear in the literature 5cm preop will expand to 7-8cm on

rectal mobilization This will shrink to 2-3cm with

specimen removal and formalin fixation

Rare for tumour to spread beyond 1.5cm

Rare reports of poorly diff tumours having spread 4.5cm distally

Recommend: 5cm ideally however 2cm is adequate

RECTAL CANCER OPERATIONS

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SURGICAL TECHNIQUE - LAR

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Splenic veinSplenic vein

Inferiormesentericvein

Inferiormesentericvein

DuodenumDuodenum

Inferiormesenteric

artery

Inferiormesenteric

artery

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N > 12 LNs

SURGICAL TECHNIQUE - LAR

SURGICAL TECHNIQUE - LAR

TME - Nerve injury

Pre-aortic sympathetics during high ligationSympathetics at the pelvic brim during rectal

mobilizationParasymp(nervi erigentes) and sympathetics during

posterolateral dissection No clear lateral ligaments Do not hook or clamp these tissues, avoid excessive traction Higher rates with extended lateral LN dissection

Anterior lateral dissection off the prostatic capsule The most likely area of damage, reflected by higher rates of

sexual dysfunction in APR(14-51%) vs AR(9-29%) The role of Denonvilliers’ fascia

Hypogastric Nerve Plexus

Reconstruction of Neorectum

Hand sewn sutured anastomosis 1982: Parks and Percy performed the colo-anal sutured anastomosis ‘Pulled through’ coloanal anastomosis (Turnbull & Cuthbertson)

Stapled anastomosis Circular stapled technique Double staple technique

For low and coloanal anastomosis

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RoticulatorRoticulator

AA B

CC DD EE

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Knight and Griffen, 1980Knight and Griffen, 1980

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Endo Anal vs Stapled anastomosisEndo Anal vs Stapled anastomosis

• Better function with stapler but preferable to

do endo- anal anastomosis :

1. Intersphincteric dissection

2. Very narrow pelvis

3. Enlarged prostate

4. Prior radiation for prostate cancer

5. Short margin !

• Better function with stapler but preferable to

do endo- anal anastomosis :

1. Intersphincteric dissection

2. Very narrow pelvis

3. Enlarged prostate

4. Prior radiation for prostate cancer

5. Short margin !

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Colo-anal anastomosisColo-anal anastomosis

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Reconstruction of Neorectum

Straight end to end Low AR or Colo-anal end-to-end anastomosis cause tenesmus, urgency

and incontinence (Anterior resection or “post-proctectomy” syndrome)

Colonic J - Pouch Increases volume of neorectum 5 vs 10cm pouches have smaller reservoirs but better evacuation Size is critical to functional outcome, recommend 5-8 cm Sigmoid colon should not be used Better short term functional results and possible lower anastomotic

leaks compared to end-to-end anastomosis

Transverse Coloplasty Better in narrow pelvis and limited length of colon Long incision closed transversely Randomized trial underway comparing to J-pouch

COLORECTAL – COLOANAL ANASTOMOSIS

“Straight” End to End Anastomosis

Transverse Coloplasty

COLONIC NEORECTUM

Colonic J - Pouch

COLONIC NEORECTUM

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INTERSPHINCTERIC RESECTION

INTERSPHINCTERIC RESECTION – COLOANAL ANASTOMOSIS

INTERSPHINCTERIC RESECTION

TRANSABDOMINAL – TRANSANAL INTERSPHINCTERIC RESECTION

Intersphincteric Resection versus Stapled Coloanal Anastomosis for Low Rectal

CancerJ Korean Soc Coloproctol. 2008 Apr;24(2):113-120

Intersphincteric Resection versus Stapled Coloanal

Anastomosis for Low Rectal CancerJ Korean Soc Coloproctol. 2008 Apr;24(2):113-120

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Indications for APRIndications for APR

• Inadequate sphincter : low Hartmann? • Sphincter invasion• Inadequate margin• Fecal Incontinence• Patient wishes !

• Inadequate sphincter : low Hartmann? • Sphincter invasion• Inadequate margin• Fecal Incontinence• Patient wishes !

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First report of APR technique at MayoFirst report of APR technique at Mayo

Abdominoperineal Resection

Described by Sir Ernest Miles 1908 1-2 surgeons TME rectal dissection Anus sutured closed Wide perineal dissection, starting from posterior to lateral

then anterior Anterior dissection can proceed cranio-caudal or vice versa SB exclusion - omentum or absorbable mesh Drain the pelvic space Reduced rates of APR

Coloanal anastomosis Acceptance of smaller margins Downsizing by chemoradiotherapy

Abdominoperineal Resection

SURGICAL ANATOMY OF THE RECTUM

Abdominoperineal Resection

APR – Cylindrical Resection

TEM

TRANSANAL ENDOSCOPIC MICROSURGERY

TEM Full thickness excision with 1cm margin including mesorectal fat Rectal defect closed transversely T1 and/or T2 Rectal Tumors Occult Locoregional Metastases (20% to 33%) Local Recurrence Rate is still High and more than double compared to

radical surgery. T1(15%) T2(47%)

Overall Survival is NOT significantly different T1(72-90%) T2(55-78%)

Heafner TA, Glascow SC. A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors. J Gastrointest Oncol 2014

TRANSANAL ENDOSCOPIC MICROSURGERY

Transanal Endoscopic Microsurgery (TEM) Developed for lesions out of reach from transanal approach Favourable T1 lesions have equivalent local recurrence and 5yr

survival comparable to radical surgery Unfavourable T1 lesions have higher local recurrence (10-15%) TEM + XRT on T2 have local recurrence (25-46%) Neoadjuvant CRT in T1-2 lesions may achieve CR (50%)

TRANSANAL ENDOSCOPIC MICROSURGERY

Indications:

1. Well – moderately differentiated tumors

2. No lymphovascular invasion

3. No perineural invasion

4. No mucinous components

5. < 3 cm in size

6. Clear margin of resection

7. < 3 cm of bowel circumference

8. Mobile / nonfixed

9. Early T1 and T2 rectal tumors

10. No nodal disease

11. < 10 cm from the anal verge

LOCALLY ADVANCED RECTAL CANCER

Laparoscopic Resection for Rectal Cancer

Should we do it?

LAPAROSCOPIC TME

Potential Advantages of Lap TME

• Less blood loss• Faster recovery• Earlier return of gut function• Lower morbidity• Magnified view allows precise dissection

(pelvic autonomics)

Potential Advantages of Lap TME

• Reduced pain• Improved cosmesis• Decreased adhesions• Decreased wound infection rate• Reduced immune effect of surgery

Potential Disadvantages

• Steep learning curve• Longer operating times (+30% to 50%)• Cost

– Instruments / equipment

• Port-site recurrence?• Oncological soundness compared with open

TME?

Potential Disadvantages

• Practical and technical limitations – Crowding of instruments in the pelvis– Plume can obscure vision– Retraction of the rectum can be very difficult– Division of the rectum can be difficult– Identification of tumour site can be difficult– Pneumoperitoneum

• Gas embolism / decreased venous return

Laparoscopic Resection for Rectal Cancer: What is the Evidence?

Dedrick Kok HC, et al. Biomed Res Int 2014

Long – Term Results in Rectal Cancer

Lai JH, et al. Br Med Bull 2012

Laparoscopic Resection for Rectal Cancer: What is the Evidence?

Dedrick Kok HC, et al. Biomed Res Int 2014

Open versus Laparoscopic surgery for mid-rectal or low-rectal cancer after

neoadjuvant chemoradiotherapy (COREAN trial): Survival Outcomes.

Findings:

We randomly assigned 340 patients with rectal cancer to receive either open surgery (n=170) or laparoscopic surgery (n=170), after neoadjuvant chemoradiotherapy

3 year disease-free survival was 72·5% (95% CI 65·0–78·6) for the open surgery group and 79·2% (72·3–84·6) for the laparoscopic surgery group

Jeong SY, et al. Gastrointestinal Cancer 2014

Factors Of Prognostic Significance (Surgeon Related)

1) Extent of margins of resection

2) Extent of lymphatic resection

3) Timing and level of vascular ligation

4) TME Technique

5) Anastomotic technique

6) Intraluminal cytotoxic solutions

Conclusions

TEM in favorable T1 lesions

TME the standard practice in rectal dissection

High vascular ligation

Nerve preservation surgery

Role of distal margins

Sphincter – preserving surgery

Laparoscopic TME feasible and oncologically acceptable

Rectal cancerRectal cancer

SURGEON

MEDICAL ONCOLOGIST

RADIOTHERAPIST

CUREQOL

PATHOLOGIST

STOMA THERAPIST NURSE

RADIOLOGIST